**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident representative interview, and staff interview, the facility failed to notify Resident #97's legal representative when he passed away in the facility and notify the resident representative of a new medication. This was a random opportunity for discovery. Resident identifiers: #97 and #76. Facility census: 93.Findings included: a) Resident #97 On [DATE] at 8:55 AM, an electronic record review revealed: Resident #97’s legal representative’s home telephone number Resident #97’s legal representative’s mobile phone number A Physician Orders for Scope of Treatment (POST) form dated [DATE] The POST form listed the legal representative’s mobile phone number A Care Conference note, dated [DATE] at 10:00 AM, indicated Resident #97’s legal representative participated in the meeting A Nursing Note, dated [DATE] 2:40 PM, which indicated the nurse had made Resident #97’s legal representative aware of a new skin issue A Nursing Note, dated [DATE] at 8:57 PM, indicated the legal representative was made aware of a new physician order for occupational therapy to evaluate and treat resident A Nutrition/Dietary note, dated [DATE] at 3:42 PM, indicated Resident #97’s legal representative was made aware of a new dietary supplemental order for resident A Nursing Note, dated [DATE] at 4:13 Am, indicated that the legal representative had visited the building the day prior and was aware of a new dietary order A Nursing Note, dated [DATE] at 11:52 AM, indicated that the resident’s family had taken resident out of the building to attend a family reunion A Nursing Note, dated [DATE] at 3:54 PM, indicated the resident had returned to the facility with two (2) skin tears to the top of left hand. A Nursing Note, dated [DATE] at 4:46 PM, indicated the nurse spoke to Resident #97’s legal representative about the new skin tears. A Nursing Note, dated [DATE] at 1:13 PM, indicated the resident’s legal representative had visited the facility on this date. Palliative care services, a specialized form of medical care that focuses on improving the quality of life for people with serious or life-limiting illnesses, were discussed. A Nursing Note, dated [DATE] at 8:53 PM, indicated the nurse had attempted to call resident’s legal representative to let the individual know the resident was not doing well. The note indicated the nurse was unable to reach the legal representative at either number listed. A Nursing Note, dated [DATE] at 12:59 AM, indicated a Nurse Aide (NA) called the nurse to Resident #97’s room. Upon assessment, the resident was not breathing, no breath sounds were heard, and the resident had no pulse. A Nursing Note, dated [DATE] at 1:56 AM, indicated the nurse attempted both numbers for resident’s legal representative but was unable to reach the representative. The nursing note also documented that the funeral home was notified of resident’s death at 1:09 AM. Additionally the note indicated resident’s watch and silver bracelet were sent to the funeral home with resident. Review of the facility’s policy, entitled “Death of a Resident – Documenting”, outlined the appropriate documentation that should be make in the clinical record concerning the death of a resident. The guidance listed: 1. A resident may be declared dead by a licensed physician or registered nurse with he physician authorization in accordance with state law. 2. All information pertaining to a resident’s death (i.e., date, time of death, the name and title of the individual pronouncing the resident death etc.) will be recorded on the nurses’ notes. 3. The attending physician will record the cause of death in the medical record and will complete and file a death certificate with the appropriate agency in accordance with state law. 4. The licensed nurse or designee will inform the resident’s family and/or resident representative of the resident’s death. 5. Nursing services will be responsible for preparing the deceased resident for discharge. 6. A physician’s order to release the body will be obtained and documented in the medical record. 7. The licensed nurse / designee must notify the mortician, as identified in the resident’s medical record, to pick up the deceased resident. During a telephone interview on [DATE] at 9:30 AM, Resident #97’s legal representative reported that she had never received a telephone call from the nursing home regarding her loved one’s death. The legal representative reported she had caller ID and voicemail and that she never showed a missed call from the facility nor did she have a voicemail message from the facility. She reported she had been home all evening and all night. The legal representative reported she received a call from the funeral home at approximately 9:30 AM stating they had her loved one’s body and wanting to discuss funeral arrangements. This was reportedly the first time she learned that her loved one had passed away at the nursing home. The legal representative reported she was devastated to get the news in that manner. She went on to report that she waited the entire day to receive a call from the facility but never did. In an interview on [DATE] AM at 11:40 AM, the Administrator acknowledged Resident #97’s legal representative had been actively involved in the resident’s care both via telephone calls and visits to the facility. Additionally, The Administrator acknowledged the nursing staff was unable to produce evidence that they had successfully notified Resident #97’s legal representative of his death. The Administrator stated it was a terrible oversight and had been addressed with the staff involved. b) Resident #76 On [DATE] at approximately 3:30 PM, a record review was completed for Resident #76. The review found the resident had seen MindCare Psychiatric Evaluation via video on [DATE]. The progress note dated [DATE] at 8:50 AM, stated, Vistaril 25mg (milligram) by mouth every eight (8) hours as needed for 14 days for anxiety. However, upon further review, the resident's Medical Power of Attorney (MPOA) was not notified. There was no change in condition completed. An interview was held with the resident's representative on [DATE] at approximately 4:15 PM. The MPOA was asked, do you feel the (Name of Resident) is anxious or having problems with anxiety? The MPOA replied, no, I don't. On [DATE] at approximately 4:30 PM, the Administrator was interviewed regarding the change of condition for the resident and the adding of a new medication. The Administrator stated, there should be a change in condition and a note stating the MPOA was notified.

Based on record review and staff interview, the facility failed to provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 93. Findings Include: Based on record review and staff interview, the facility failed to provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 93. Findings Include: a) Resident #10 On 08/25/25 at 2:00 PM, a record review was completed for Resident #10. The review found the PAS dated 07/01/24 did not include the diagnosis of generalized anxiety disorder (GAD). The diagnosis of generalized anxiety disorder was added during the stay at the facility on 06/16/23. On 08/25/25 at 2:58 PM, the Social Service Worker #22 confirmed the diagnosis of generalized anxiety disorder was not on the PAS dated 07/01/24. The Social Services Worker #22 stated, I'll get this corrected.

Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #5. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #5. Facility Census: 93.On 08/25/25 at 2:30 PM, a record review was completed for Resident #5. The review found a physician's order for Lamictal 200mg (milligram) one (1) tablet by mouth at bedtime for seizures. A review of the resident's diagnoses did not find the diagnosis of seizures.On 08/25/25 at 3:30 PM, the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #13 confirmed the resident did not have seizures and the correct diagnosis should be mood disorder. On 08/25/25 at 3:45 PM, the MDS LPN #13 stated, We will get this corrected.

Based on resident interview, staff interview and observation the facility failed to provide a safe, clean, comfortable, homelike environment for residents. This is true for residents #58, #79, #87, and #40. Facility Census 93.Findings Included:a) Resident #58 Interview with Resident # 58 on 08/20/2025 at 2:38 PM who reported a black area on the tile on and around the base of the wall behind resident’s toilet. Observed area around resident's toilet at 2:41 PM and Nurse Aide (NA) #35 acknowledged the area and agreed to notify housekeeping/maintenance. b) Resident #79 On 08/20/2025 at 10:47 AM during an interview with Resident #79, he stated pieces of dry wall had been removed from the bathroom wall around the pipes to the toilet for approximately one month. The toilet is now working but he did not have access to his toilet for two weeks, he had to use the toilet at the nurse’s station. c) Resident #87 Observed on 08/20/2025 10:53 AM a large hole in ceiling exposing unfinished wood underneath. d) Resident #40 On 08/20/25 at 1:20 PM observed Resident's toilet lid sitting on the floor beside the toilet. On 08/20/25 at 1:24 PM interview with Nurse Aide #72 who reported as far as she knew, the toilet was broken. On 08/20/25 at approximately 1:30 PM during an interview with Regional Director of facilities for Maintenance #116, he acknowledged the hole in ceiling to Resident #87 room, Resident #79 dry wall in bathroom, the toilet lid and dirty bathroom to Resident #40 room and acknowledged the black substance on tile and rubber base board of the wall in bathroom of Resident #58 bathroom. He began working to correct these issues immediately.

Based on observation and staff interview the kitchen failed to store food in accordance to professional standards for food safety. Facility census: 93.Findings Included: a) During initial kitchen walk through on 08/20/25 the following items we found in the walk-in refrigerator: six (6) quarts of cranberry juice with a use by date of 08/08/25 five (5) Fruit Punch pitcher use by date of 08/18/25 three (3) grape drinks use by 08/15/25 four (4) sugar free drink use by 08/18/25 Unsweet tea use by 08/18/25 Interview with Kitchen Manager at 7:50 AM who acknowledged the drinks found in the walk-in refrigerator. Review of document titled, Receiving and Storage of Food, Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Specific Procedures/Guidance, Number eight (8) states the following: All foods stored in the refrigerator or freezer will be covered, labeled and dated (used by date). Dry food storage during initial walk through: - 6.63 lb. Sysco Classic Spaghetti Sauce dented During an interview with Kitchen Manager (KM) at 7:50 AM the KM acknowledged the dented can. Nourishment Rooms were observed on 08/21/25 and the following were found: Pantry near first hall had 70 [NAME] crackers individually wrapped, undated and in an unmarked drawer with other foods and snacks such as peanut butter. Pantry near second hall had 25 [NAME] Crackers individually wrapped, undated and in an unmarked container. On 08/21/25 at 11:10 AM during an interview with the Regional Kitchen Manager (RKM) RKM reported that when lunch snacks were taken to the nourishment rooms, the boxes were labeled and dated as far as the lunch cakes were concerned. RKM was not aware as to why the graham crackers were not labeled and continually placed in the drawer but would do an in-service. A review of a document titled Receiving and Storage of Food revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Guidance #7 Dry foods that are stored in bins will be removed from original packaging, labeled and dated use by date.

Based on observation, policy review, and staff interview the facility failed to properly contain kitchen waste in garbage dumpsters in a safe and sanitary manner. Facility Census: 93.Findings Included:On 08/20/25 at 10:15 AM, facility dumpsters were observed overflowing, lids would not close on any dumpster, soiled gloves, bags and miscellaneous trash were around all sides of the dumpster. On 08/20/25 at 10:21 AM, the Administrator was notified and confirmed the dumpsters were overflowing, lids would not close and miscellaneous trash was around dumpsters. The Administrator stated, I'll call them they will make a special trip .they usually come on Tuesdays, Thursdays and Saturdays.Document titled Food-Related Garbage and Refuse Disposal was reviewed and revealed the following: Policy: Food-related garbage and refuse are disposed of in accordance with current state laws. Specific Procedures/Guidance under #7 stated Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on record review and staff interview, the facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) on non-coverage liability notices in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification throughout the Long-Term Care Survey Process. This failure placed the resident at risk of not being informed of her appeal rights prior to the end of Medicare covered services. Resident identifier: #25. Facility census: 86. Findings included: a) Resident #25 On 06/05/24 at 10:43 AM, a review regarding the beneficiary protection notification liability notice process revealed the following details: -Resident #25 remained in the facility after her Skilled Medicare ended. -Resident #25's last covered day of Part A service was 01/11/24. -A NOMNC was issued on 01/15/24 (four days AFTER skilled coverage ended) and signed by resident's representative on 01/17/24. -A SNF ABN was issued on 01/15/24 (four days AFTER skilled coveraged ended) and signed by resident's representative on 01/17/24. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: - not medically reasonable and necessary; or - considered custodial. On 06/10/24 at 12:05 PM, the Business Office Manager (BOM) confirmed that a two (2) day notice was not given for Resident #25.

Based on record review, resident interview, and staff interview, the facility failed to implement their abuse policies for reporting neglect. This deficient practice had the potential to affect one (1) of 11 residents reviewed for the care area of abuse. Resident identifier: #29. Facility census: 86. Findings included: a) Resident #29 The facility's policy and procedure titled Abuse Investigation and Reporting with original date 10/01/21 and no revision date stated all alleged violations involving neglect would be reported to the stated licensing/certification agency responsible to for surveying/licensing the facility, the local/state ombudsman, and also Adult Protective Services, if applicable to state law. During an interview on 06/03/24 at 1:39 PM, Resident #29 stated she had been left outside alone in the courtyard four (4) times following smoke breaks. Resident #29 stated she is unable to propel her wheelchair independently due to tremors and was unable to reenter the facility on her own. Resident #29 further stated there was no way to notify staff that she was outside and wanted to come in. The resident stated she was left out in the hot sun for two (2) hours on one day. Resident #29 also stated she had a history of falling from her wheelchair. Review of facility grievance forms showed a grievance on 05/13/24 which stated, Resident went outside with staff assistance for 1 pm smoke break. At end of smoke break as everyone returned inside [Nursing Assistant (NA) #5] said to this patient, If you can't bring yourself outside or inside, you shouldn't be able to smoke. [NA #5] then entered the building leaving this resident out in the courtyard unattended. Another resident [Resident #79] noted this patient outside alone and alerted staff. [NA #9] assisted this patient with returning to bed after 2 PM. Review of Resident #29's medical records showed a nursing note written on 5/22/2024 at 5:30 PM stated, CNA [certified nursing assistant] came to this nurse reporting resident was left outside by herself from a smoke break, patient was on the phone with [state agency] while she was present. CNA said she wanted me to be aware of. I went to patients room, patient was very tearful, she reported to this nurse that [Licensed Practical Nurse LPN #55] took her out to smoke, left her and no one returned to bring her back, says she was outside in the heat for over an hour. Patient was very upset and crying . (Note typed as written.) Vital signs were obtained and were within normal limits. Another nursing note written on 5/24/2024 at 6:28 PM, stated, This resident and another female resident from A/B side, along with male resident from C hall was offered help to come back in from smoke break. This resident and others said they were not ready at this time to come back in. All other smokers already have come back in at this time. Two of these residents is able to take self in and out of the door and were instructed that when they were ready to come in to please come get a staff member to assist this resident inside. Verbalized understanding. (Note typed as written.) Further review of Resident #29's medical records showed on 04/28/24 at 8:40 PM, the resident was found on the floor of her room in front of her wheelchair. The resident reported she had slid out of her wheelchair onto the floor. The resident received no injuries from this fall. Review of Resident #29's comprehensive care plan showed the resident required assistance of one (1) for mobility in a wheelchair. On 06/04/24 at 4:26 PM, observation of the facility courtyard was made with the Maintenance Director in attendance. No call lights were present in the courtyard. There was no push button to open the door for residents in wheelchairs to use. During an interview on 06/05/24 at 4:15 PM, the Administrator stated she was aware of two (2) instances during which Resident #29 had requested to remain outside after the smoke break had ended, 05/13/24 and 05/22/24. The Administrator confirmed the resident was not able to reenter the facility on her own. The Administrator stated she had not considered leaving the resident outside unattended to be neglectful, and therefore, the incident had not been reported to state agencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to thoroughly investigate and alleged verbal abuse and neglect. PS AC a)86 b)29 Resident #86 Abuse Based on a resident complaint, interviews, and record review, the facility failed to protect resident from verbal abuse, which resulted in the resident experiencing a negative psychosocial outcome, and a decline from her former social pattern This failed practice had the potential to affect a limited number of residents who currently reside in the facility. This was a random opportunity for discovery. Resident Identifiers: #86. Facility Census: 86 During an interview with Resident #86 on 06/03/24 at 11:56 AM, the resident mentioned that she was verbally abused, and threatened by Resident #11. She also stated that based on her complaint, facility staff offered her a room change. Resident states that she refused, and questions why she would be the one to have to move to another floor! Findings include: Record review and interviews that substantiate Resident #86's allegations. A nursing note on 05/27/24 at 03:30 PM by the Assistant Director of Nursing (ADON) #58 which stated: Coordinator #56 and myself went to residents room after it was reported that she was crying and feeling very anxious. Upon entering the room, the resident was breathing quickly and stated she has a history of panic attacks. She stated she was very upset with recent interactions she has had with a resident further down the hall. She states she had previously come in her room, she did not touch her but shook her fist at her. She also stated, when she attacked me in the hall, I asked if she touched her in the hall and she again said oh no she just shook her fist at me and made a mean face. We assured resident that we were addressing the issue. She then said she was scared to go to the bathroom, we offered assistance and she denied. She said she was getting ahold of her brother to take her home today. We offered a room move which she denied. She stated again she was just deathly afraid of this resident and that she would go on a different hall in the facility to avoid her. Prior to this conversation I spoke with resident's daughter on the phone about these same concerns and also reassured her that we were addressing the issue. Resident states as the resident down the hall wheels by her room she looks at her and she does not like it. Prior to exiting the room, I pulled curtain to the edge of bed with resident approval to avoid visual contact if she happened to roll by. Another note on 5/27/2024 at 08:30 PM by LPN #60 states: Resident crying in her room. When this nurse asked resident what was wrong, resident talking in a loud tone stating, I'm over this place, all this stuff that happened earlier today and nobody does anything about it, they continue to allow the other resident to do as she wants, she's allowed to go up and down the halls as she pleases when she should be in her room. They try to make me feel like I'm in the wrong. Resident also stating she wasn't taking anymore medications while in this facility and that she would be leaving tomorrow one way or another. This resident stating she didn't want to be here any longer because of the way other resident's act and stating they need to be placed into different facilities than this one. Resident also stating that she would be filing a lawsuit on this place and could file restraining orders against the other resident. This resident was very tearful during this encounter which lasted approximately 5-6 minutes. interventions attempted: This nurse offered this resident to move to a different room to not have to see the other resident that there was previous conflict with, this resident refused. Curtains on each side of this resident was pulled (per her request) to not have to see anyone. A progress note from Resident #11's chart on 05/27/24 at 08:52 PM by LPN #63 states that a CNA reported that she was standing outside room [ROOM NUMBER] (Resident #86's room), when she saw this resident wheel past the room and point to the other resident and tell the resident in 314 that she was going to kill her. Resident was redirected away from doorway. A nursing note on 05/28/24 at 06:13 AM states that resident was awake most of the night. She had stripped her bed and didn't want staff to assist in remaking the bed. A nursing note on 05/28/24 at 12:02 PM by the Director of Nursing (DON) #49, states: Spoke to resident regarding interaction between herself and another resident yesterday. This resident was explaining what happened, stating the other resident was yelling things at her and other residents. When I offered a room change, the resident stated no, I'm working on being transferred to another facility today. When this nurse asked if she wanted a stop sign to put on her doorway, she stated no. The resident was also noted to be sitting in her bed w/o bed sheets on the bed. Staff have reported she took her sheets off and is refusing to allow staff to put new linens on the bed. Call light is within reach. This nurse notified Administrator #48, and Social Worker (SW) #44 of residents wishes to discharge somewhere else. During an interview on 06/05/24 at 9:45 AM with Coordinator # 56 she was questioned about interventions that were taken to prevent a recurrence of the behavior and threats against Resident #86? She stated that Resident #11 had a private room and could not be moved to another location because she was diagnosed with dementia. She stated that moving Resident #11 would increase the risk of resident being harmed. Based on a resident complaint, interviews, and record review, the facility failed to report allegations of abuse. This failed practice had the potential to affect a limited number of residents who currently reside in the facility. This was a random opportunity for discovery. Resident Identifiers: #86. Facility Census: 86 Findings include: During an interview with Resident #86 on 06/03/24 at 11:56 AM, the resident mentioned that she was verbally abused, and threatened by Resident #11. She also stated that based on her complaint, facility staff offered her a room change. Resident states that she refused, and questions why she would be the one to have to move to another floor. Resident further stated that on 05/28/24, she had asked her son to call the Office of Health Facility Licensing and Certification (OHFLAC) and make a complaint. Investigation, and a review of submitted reports, revealed that the facility had submitted a report of the abuse to the Ombudsman, but not to OHFLAC. An interview with Administrator #48 on 06/05/24 02:42 PM revealed that the facility had not submitted a Facility Incident Report (FRI) to OHFLAC. She stated that the facility followed the reporting requirements laid out in 42 CFR 488.301, which listed actions to be taken. The copy of the guidance for reporting, she provided as evidence, stated: Abuse Resident-to-Resident - No sexual abuse occurred, and no physician intervention was required - A report only to the Ombudsman was required, unless the incident was caused by lack of staff or encouraged by staff. A review of the document provided to this surveyor revealed that the facility was not utilizing the current guidelines for reporting. Based on a resident complaint, interviews, and record review, the facility failed to investigate, prevent and correct the allegations of abuse. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. This was a random opportunity for discovery. Resident Identifiers: #86. Facility Census: 86. Record review revealed a nursing note entered on 05/27/24 at 03:30 PM by the Assistant Director of Nursing (ADON) #58 which stated: Coordinator #56 and myself went to residents room after it was reported that she was crying and feeling very anxious. Upon entering the room, the resident was breathing quickly and stated she has a history of panic attacks. She stated she was very upset with recent interactions she has had with a resident further down the hall. She states she had previously come in her room, she did not touch her but shook her fist at her. She also stated, when she attacked me in the hall, I asked if she touched her in the hall and she again said oh no she just shook her fist at me and made a mean face. We assured resident that we were addressing the issue. She then said she was scared to go to the bathroom, we offered assistance and she denied. She said she was getting ahold of her brother to take her home today. We offered a room move which she denied. She stated again she was just deathly afraid of this resident and that she would go on a different hall in the facility to avoid her. Prior to this conversation I spoke with resident's daughter on the phone about these same concerns and also reassured her that we were addressing the issue. Resident states as the resident down the hall wheels by her room she looks at her and she does not like it. Prior to exiting the room, I pulled curtain to the edge of bed with resident approval to avoid visual contact if she happened to roll by. Another note on 5/27/2024 at 08:30 PM by LPN #60 states: Resident crying in her room. When this nurse asked resident what was wrong, resident talking in a loud tone stating, I'm over this place, all this stuff that happened earlier today and nobody does anything about it, they continue to allow the other resident to do as she wants, she's allowed to go up and down the halls as she pleases when she should be in her room. They try to make me feel like I'm in the wrong. Resident also stating she wasn't taking anymore medications while in this facility and that she would be leaving tomorrow one way or another. This resident stating she didn't want to be here any longer because of the way other resident's act and stating they need to be placed into different facilities than this one. Resident also stating that she would be filing a lawsuit on this place and could file restraining orders against the other resident. This resident was very tearful during this encounter which lasted approximately 5-6 minutes. interventions attempted: This nurse offered this resident to move to a different room to not have to see the other resident that there was previous conflict with, this resident refused. Curtains on each side of this resident was pulled (per her request) to not have to see anyone. Investigation and record review of Resident #11's chart revealed a progress note on 05/27/24 at 08:52 by LPN #63 that stated a CNA reported that she was standing outside room [ROOM NUMBER] (Resident #86's room), when she saw this resident wheel past the room and point to the other resident and tell the resident in 314 (Resident #86) that she was going to kill her. Resident was redirected away from doorway. A nursing note on 05/28/24 at 06:13 AM by LPN #60 stated: Resident awake most of the night lying in her bed. Resident stripped her own bed and didn't' want staff to assist remaking bed. Resident is able to voice wants/needs. Denies any needs at this time. Resident encouraged to use call light for assistance, resident voices understanding. Call light and fluids are within reach. A nursing note on 05/28/24 at 12:02 PM by the Director of Nursing (DON) #49, states: Spoke to resident regarding interaction between herself and another resident yesterday. This resident was explaining what happened, stating the other resident was yelling things at her and other residents. When I offered a room change, the resident stated no, I'm working on being transferred to another facility today. When this nurse asked if she wanted a stop sign to put on her doorway, she stated no. The resident was also noted to be sitting in her bed w/o bed sheets on the bed. Staff have reported she took her sheets off and is refusing to allow staff to put new linens on the bed. Call light is within reach. This nurse notified Administrator #48, and Social Worker (SW) #44 of residents wishes to discharge somewhere else. Further record review revealed a note on 05/30/24 at 15:30 by SW #44 which stated: This worker sent out a referral to Pineview Center per the resident's request. This worker spoke to Misty [NAME], the social worker at this facility, who stated she would look it over as well as have her admissions director look over it. Waiting for a response at this time. During an interview on 06/05/24 at 9:45 AM with Coordinator # 56 she was questioned about interventions that were taken to prevent a recurrence of the behavior and threats against Resident #86? She stated that Resident #11 had a private room and could not be moved to another location because she was diagnosed with dementia. She stated that moving Resident #11 would increase the risk of resident being harmed. Following the investigation, interviews, and record review it is evident that the facility failed to put in place procedures/safeguards intended to prevent recurrence of the abuse and provide Resident #86 with psychosocial services to address the abuse. b) Resident #29 During an interview on 06/03/24 at 1:39 PM, Resident #29 stated she had been left outside alone in the courtyard four (4) times following smoke breaks. Resident #29 stated she is unable to propel her wheelchair independently due to tremors and was unable to reenter the facility on her own. Resident #29 further stated there was no way to notify staff that she was outside and wanted to come in. The resident stated she was left out in the hot sun for two (2) hours on one day. Resident #29 also stated she had a history of falling from her wheelchair. Review of facility grievance forms showed a grievance on 05/13/24 which stated, Resident went outside with staff assistance for 1 pm smoke break. At end of smoke break as everyone returned inside [Nursing Assistant (NA) #5] said to this patient, If you can't bring yourself outside or inside, you shouldn't be able to smoke. [NA #5] then entered the building leaving this resident out in the courtyard unattended. Another resident [Resident #79] noted this patient outside alone and alerted staff. [NA #9] assisted this patient with returning to bed after 2 PM. Review of Resident #29's medical records showed a nursing note written on 5/22/2024 at 5:30 PM stated, CNA [certified nursing assistant] came to this nurse reporting resident was left outside by herself from a smoke break, patient was on the phone with [state agency] while she was present. CNA said she wanted me to be aware of. I went to patients room, patient was very tearful, she reported to this nurse that [Licensed Practical Nurse LPN #55] took her out to smoke, left her and no one returned to bring her back, says she was outside in the heat for over an hour. Patient was very upset and crying . (Note typed as written.) Vital signs were obtained and were within normal limits. Another nursing note written on 5/24/2024 at 6:28 PM, stated, This resident and another female resident from A/B side, along with male resident from C hall was offered help to come back in from smoke break. This resident and others said they were not ready at this time to come back in. All other smokers already have come back in at this time. Two of these residents is able to take self in and out of the door and were instructed that when they were ready to come in to please come get a staff member to assist this resident inside. Verbalized understanding. (Note typed as written.) Further review of Resident #29's medical records showed on 04/28/24 at 8:40 PM, the resident was found on the floor of her room in front of her wheelchair. The resident reported she had slid out of her wheelchair onto the floor. The resident received no injuries from this fall. Review of Resident #29's comprehensive care plan showed the resident required assistance of one (1) for mobility in a wheelchair. On 06/04/24 at 4:26 PM, observation of the facility courtyard was made with the Maintenance Director in attendance. No call lights were present in the courtyard. There was no push button to open the door for residents in wheelchairs to use. During an interview on 06/05/24 at 4:15 PM, the Administrator stated she was aware of two (2) instances during which Resident #29 had requested to remain outside after the smoke break had ended, 05/13/24 and 05/22/24. The Administrator confirmed the resident was not able to reenter the facility on her own. The Administrator stated she had not considered leaving the resident outside unattended to be neglectful and therefore, the incident had not been investigated. No additional information was provided through the completion of the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #39 On 06/04/24 at 10:03 AM, a review of Resident #39's medical record revealed that Resident #39 had been hospitalized from [DATE] through 04/10/24 Further review of Resident #39's medical record revealed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative or that the Ombudsman was notified of the discharge on [DATE]. On 06/11/24 at 9:50 AM, during an interview with the facility Social Worker (SW), the SW confirmed there was no evidence that the Notice of Transfer or Discharge was completed and provided to the Resident's Representative for the discharge on [DATE]. The SW also confirmed the Ombudsman was not notified of the discharge on [DATE]. Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer/discharge and failed to notify the long-term care Ombudsman of the transfer. This was true for two (2) of three (3) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident identifiers: #191,and #39. Facility census: 86. Findings included: a) Resident #191 A record review, completed on 06/10/24 at 2:24 PM, revealed that Resident #191 had been transferred to the hospital on [DATE]. There was no evidence in the electronic medical record that the facility had provided Resident #191 or his representative with a written Notice of Transfer/Discharge form nor was there evidence the facility had notified the Long-Term Care Ombudsman of resident's transfer to the hospital. During an interview, on 06/11 /24 at 11:20 AM, the Medical Records Director reported the facility could not produce evidence that a Notice of Transfer/Discharge form for Resident #191's hospitalization on 05/25/24. The Medical Records Director also reported there was no evidence the Long-Term Care Ombudsman had been notified of the resident's transfer. b) Resident #34 Medical Record review on 06/10/24 revealed resident #34 was discharged to the hospital on [DATE]. Subsequent review of Resident #34's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman was notified of the discharges on 06/02/24. On 06/11/24 at 9:50 AM during an interview the Social Worker verified, there was no evidence that the Notice of Transfer or Discharge was completed and provided to the Resident's Representative for the discharges on 06/02/24. The Social Worker also confirmed the Ombudsmen was not notified of the discharges on 06/02/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #39 On 06/04/24 at 10:03 AM, a review of Resident #39's medical record was complete. It was noted during this review that Resident #39 had been hospitalized from [DATE] through 04/10/24. Further review of Resident #39's medical record revealed it did not contain documentation that the Notice of Bed Hold Policy was provided to the Resident's Representative at the time of the hospitalization on 04/01/24. On 06/11/24 at 9:50 AM, during an interview with the facility Social Worker (SW), the SW confirmed there was no evidence that the Notice of Bed Hold Policy was provided to the Resident's Representative for the hospitalization on 04/01/24. Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided a written Bed Hold notice for an acute hospital transfer. This was true for two (2) of three (3) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident identifiers: #191, #34. Facility census: 86. Findings included: a) Resident #191 A record review, completed on 06/10/24 at 2:24 PM, revealed that Resident #191 had been transferred to the hospital on [DATE]. There was no evidence in the electronic medical record that the facility had provided Resident #191 or his representative with a written Bed Hold notice. During an interview, on 06/11 /24 at 11:20 AM, the Medical Records Director reported the facility could not produce evidence that a Bed Hold notice had been issued for Resident #191's hospitalization on 05/25/24. b) Resident #34 Medical Record review on 06/10/24 revealed resident #34 was discharged to the hospital on [DATE]. Subsequent review of Resident #34's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman was notified of the discharges on 06/02/24. On 06/11/24 at 9:50 AM during an interview the Social Worker verified, there was no evidence that the Notice of Transfer or Discharge was completed and provided to the Resident's Representative for the discharges on 06/02/24. The Social Worker also confirmed the Ombudsman was not notified of the discharges on 06/02/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to update the PASARR for Resident #3, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: 3. Facility census: 86. Findings include: A) Resident #3 On 06/10/24, a record review was conducted for Resident #3. During record review, it was noted Resident #3 had been admitted to the facility on [DATE]. On 02/25/21, Resident #3 was diagnosed with major depressive disorder and on 10/13/23 was diagnosed with bipolar disorder. Resident #3 had a new PASARR submitted on 11/27/2023, which did not include the new diagnosis of Major Depressive Disorder or bipolar disorder. At approximately 10:04 AM on 06/11/24, an interview was conducted with the social worker concerning the PASARR for Resident #3, she confirmed the absence of major depressive disorder and bipolar disorder on the PASARR.

Based on record review and staff interview the facility failed to obtain laboratory services as ordered by the physician to meet the needs of its residents. This was true for one (1) of 1 resident reviewed for the Long-Term Survey Process. Resident identifier: #41. Facility census: 86. a) Resident #41 On 06/04/24 at 01:00 PM, a review of Resident #41's medical record was performed. During the review of the physician's orders, it was noted that Resident #41 had orders as follows: * Novolog Injection Solution (Insulin Aspart) Inject as per sliding scale: if 201- 250 = 4; 251- 300 = 6; 301- 350 = 8; 351- 400 = 10; 401- 450 = 12; 451 + = 15. Notify Medical Doctor (MD) if blood sugar (BS) is less than 60 or above 450, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM) II. Order date: 01/29/24 * Complete Blood Count (CBC)/Glycated hemoglobin (HgbA 1c) every 6 (six) months. Order date: 08/09/23. Upon further review of the medical record, this Surveyor was unable to locate the most recent results of the CBC and HgbA 1c. On 06/04.24 at 02:06 PM, an interview was conducted with the Assistant Director of Nursing (ADON). At this time, copies of the most recent results of the CBC and HgbA 1c were requested. On 06/11/24 at 09:06 AM, the ADON acknowledged that the most recent CBC and HgbA 1c had not been obtained as per orders.

Based on observation, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment. The ceiling in room B6 was damaged. This was a random opportunity for discovery. Facility census: 86. Findings included: a) Room B6 On 06/03/24 at 12:55 PM, Resident #29 asked the surveyor to look at the ceiling in her room. Several brown spots were immediately over the resident's bed. The largest was the size of a plate. In the corner of the room, near but not directly over the resident's bed, contents appearing to be drywall were extruding from a plate-sized hole in the ceiling. On 06/04/24 at 3:33 PM, the Maintenance Supervisor stated the damage in the ceiling of Room #B6 was water damage. He stated the areas would be repaired.

Based on observation and staff interview, the facility failed to provide residents with a dignified dining experience. The dining room staff failed to serve the residents in a respectful manner, by not placing the food in front of the residents and removing the trays. This failed practice was true for all twenty-three (23) residents in the dining room and had the potential to affect more than a limited number of residents who currently reside in the facility. Additionally, the facility failed to ensure that Resident #60 was treated with dignity and respect. This was a random opportunity for discovery. Resident identifier: #60. Facility census: 86. Findings included: a) Dining Observation Based on an observation on 06/03/24 at 12:08 PM, the dining room staff had failed to take the food off the trays and place it in front of the residents, rather, they had left the trays with the food in front of each resident. Serving the residents their food on trays creates the atmosphere of an institutional setting. An interview with Activity Assistant #102 on 06/03/24 at 12:11 PM, revealed that she was not aware that resident's plates were to be taken off the trays and placed in front of them. Further interviewing revealed that she was new to the dining area. She also stated that as far as she was aware, the trays were for the residents safety. She stated that it prevented the residents from knocking their food off the table. She also stated that keeping each resident's food on their tray prevented the residents from mistakenly reaching for each other's food or drink. An interview with the Dietary Manager #90 on 06/03/24 at 12:18 PM revealed that she too was unaware that food was to be served in a homelike setting. Upon being questioned, she too stated that the trays prevented residents from knocking their food off the table, and that it also prevented residents from reaching for another resident's food or drink. She further stated that this is how we have always served the meals! b) Resident #60 On 6/03/24 at 12:00 AM, an observation of the facility dining area was performed. During this observation, Resident #60 was noted to be seated at a table wearing a facility gown that was not tied at the neck or waist. The front of the gown was exposing Resident #60's upper chest, shoulders and the right side of Resident #60's back. It was noted that several facility staff walked by Resident #60 without offering to adjust or tie Resident #60's gown to cover Resident #60's exposed body areas. On 06/03/24 at 12:12 PM, a staff interview was conducted with Employee #96. During this interview, Employee #96 acknowledged that Resident #60's gown should be tied and that Resident #60's upper chest, shoulders and back of Resident #60's body should not be exposed. Employee #96 b) Resident #60 On 6/03/24 at 12:00 AM, an observation of the facility dining area was performed. During this observation, Resident #60 was noted to be seated at a table wearing a facility gown that was not tied at the neck or waist. The front of the gown was exposing Resident #60's upper chest, shoulders and the right side of Resident #60's back. It was noted that several facility staff walked by Resident #60 without offering to adjust or tie Resident #60's gown to cover Resident #60's exposed body areas. On 06/03/24 at 12:12 PM, a staff interview was conducted with Employee #96. During this interview, Employee #96 acknowledged that Resident #60's gown should be tied and that Resident #60's upper chest, shoulders and back of Resident #60's body should not be exposed. Employee #96 then went and tied Resident #60's gown.

Based on interviews, and document review, the facility failed to ensure that residents' food preferences and choices were honored. This failed policy had the potential to affect more than a limited number of residents. Resident identifiers: #17, #14, and #9. Facility Census 86. Findings included: a) Resident #17 Based on an interview, on 06/03/24, with Resident #17 at 10:13 AM, it was revealed that she was unable to order an alternate item, if the food served to them was not to their liking. She mentioned this was due to the facility policy governing the ordering of alternate food items. The policy stated that orders for any alternate items were to be placed 2 (two) hours before mealtimes. This policy prevented residents from being able to exercise their right to a choice of food during mealtimes. Further, the resident stated that she was provided with a weekly menu which required her to review that day's menu, at least two (2) hours before mealtimes, to ensure that she could order an alternate if she needed to. The resident further stated that she was occupied during the morning hours with PT and other activities, which left her with very little time to review the lunch menu and place an order for an alternative. Resident stated that the facility had previously provided a printed daily menu to them in a timely manner, and they would check off their choices or order an alternate. She stated that the current system of posted weekly menus prevents them from exercising their choices. b) Resident #14 Based on an interview on 06/03/24 with Resident #14 at 10:28 AM, the resident revealed that he was unable to order an alternate item, if he did not like the food served to him at mealtimes. He stated the facility policy governing the ordering of alternate food items made it impossible to get an alternate item during mealtimes. He stated the policy required residents to place any orders for an alternate item 2 (two) hours before meals. This facility policy prevented residents from being able to exercise their right to a choice of food during mealtimes. Further, the resident stated that the weekly menu that was provided to him required him to review it well in advance of every meal. He stated that if he forgot to check it, he would have to eat what was provided, even if he did not like the food. He stated he tried to make sure he checked the menu every day, but sometimes he forgot. He stated an alternative could be ordered at mealtime, but he would have to wait till the kitchen staff had finished serving all the residents. The resident stated the previous system of a daily menu worked better. An interview with the Dietary Manager #90 on 06/03/24 at 12:18 PM revealed the facility policy for ordering alternate items required residents to place their orders at least 2 (two) hours before mealtimes. She stated that residents could order an alternate during mealtimes, but they would have to wait a while because the cooks would be busy with the meal service.

Based on record review, resident interview and staff interview, the facility failed to identify verbal complaints/concerns as a grievance. This was a random opportunity for discovery. Findings include: a) On 06/04/24 10:00 AM, review of Resident Council Minutes for the last six (6) months indicated that the resident council voiced concerns about call lights not being answered in a timely manner every month from 12/2023 to 5/2024. On 06/04/24 10:35 AM, During resident council meeting, Resident #31 reported that staff did not answer call lights in a timely manner and that the council has discussed these issues monthly during resident council meetings. On 06/05/24 12:38 PM, during an interview with the administrator regarding call light concerns, the administrator reported the facility was aware of complaints being made in resident council meeting about call lights being answered in a timely manner. She reported that as a result, random Call Light Audits were being performed by nursing staff since 01/21/24 and reported that no issues had been found at this time. She stated that no grievances had been filed on the concern. On 06/05/24 2:00 PM during review of Call Light Audit forms. No issues documented. 06/05/24 4:31 PM, Reviewed Hill Valley Healthcare Grievance/Complaints Policy and includes the following: #3 (three) All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing. including a rationale for the response. #9 (nine) When possible and appropriate, the Grievance Officer will attempt to resolve the grievance/complaint as soon as reasonably possible. On 06/05/22 05:05 PM, during an interview with social worker (SW) #44 who acknowledged the facilities grievance policy. She acknowledged that the resident council had brought up the concern of call lights not being answered in a timely manner since at least the last 6 months. She acknowledged that although staff had reported that they are randomly auditing call light responses by having nursing completed handwritten audits, randomly every shift, there continued to be the same concern month after month for the last six (6) months. She also acknowledged that there was not a grievance filed for this issue because of the concerns brought up by resident council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) Resident #86 During an interview with Resident #86 on 06/03/24 at 11:56 AM, the resident mentioned that she was verbally abused, and threatened, by Resident #11. She also stated that based on her complaint, the only intervention facility staff offered her, was a room change. Resident stated that she refused, and questioned why she would be the one to have to move to another floor! Further record review, and interviews revealed: A nursing note on 05/27/24 at 03:30 PM by the Assistant Director of Nursing (ADON) #58 which stated: Coordinator #56 and myself went to residents' room after it was reported that she was crying and feeling very anxious. Upon entering the room, the resident was breathing quickly and stated she has a history of panic attacks. She stated she was very upset with recent interactions she has had with a resident further down the hall. She states she had previously come in her room; she did not touch her but shook her fist at her. She also stated, when she attacked me in the hall, I asked if she touched her in the hall and she again said oh no she just shook her fist at me and made a mean face. We assured resident that we were addressing the issue. She then said she was scared to go to the bathroom, we offered assistance and she denied. She said she was getting ahold of her brother to take her home today. We offered a room move which she denied. She stated again she was just deathly afraid of this resident and that she would go on a different hall in the facility to avoid her. Prior to this conversation I spoke with residents' daughter on the phone about these same concerns and also reassured her that we were addressing the issue. Resident states as the resident down the hall wheels by her room she looks at her and she does not like it. Prior to exiting the room, I pulled curtain to the edge of bed with resident approval to avoid visual contact if she happened to roll by. Another note on 5/27/2024 at 08:30 PM by LPN #60 states: Resident crying in her room. When this nurse asked resident what was wrong, resident talking in a loud tone stating, I'm over this place, all this stuff that happened earlier today and nobody does anything about it, they continue to allow the other resident to do as she wants, she's allowed to go up and down the halls as she pleases when she should be in her room. They try to make me feel like I'm in the wrong. Resident also stating she wasn't taking anymore medications while in this facility and that she would be leaving tomorrow one way or another. This resident stating she didn't want to be here any longer because of the way other residents act and stating they need to be placed into different facilities than this one. Resident also stating that she would be filing a lawsuit on this place and could file restraining orders against the other resident. This resident was very tearful during this encounter which lasted approximately 5-6 minutes. interventions attempted: This nurse offered this resident to move to a different room to not have to see the other resident that there was previous conflict with, this resident refused. Curtains on each side of this resident was pulled (per her request) to not have to see anyone. A progress note from Resident #11's chart on 05/27/24 at 08:52 PM by LPN #63 states that a CNA reported that she was standing outside room [ROOM NUMBER] (Resident #86's room), when she saw this resident wheel past the room and point to the other resident (Resident #86) and tell the resident in 314 (Resident #86) that she was going to kill her. Resident was redirected away from doorway. A nursing note on 05/28/24 at 06:13 AM states that resident was awake most of the night. She had stripped her bed and didn't want staff to assist in remaking the bed. A nursing note on 05/28/24 at 12:02 PM by the Director of Nursing (DON) #49, states: Spoke to resident regarding interaction between herself and another resident yesterday. This resident was explaining what happened, stating the other resident was yelling things at her and other residents. When I offered a room change, the resident stated no, I'm working on being transferred to another facility today. When this nurse asked if she wanted a stop sign to put on her doorway, she stated no. The resident was also noted to be sitting in her bed w/o bed sheets on the bed. Staff have reported she took her sheets off and is refusing to allow staff to put new linens on the bed. Call light is within reach. This nurse notified Administrator #48, and Social Worker (SW) #44 of residents wishes to discharge somewhere else. Further record review revealed a note on 05/30/24 at 15:30 by SW #44 which stated: This worker sent out a referral to Pineview Center per the residents' request. This worker spoke to the social worker at this facility, who stated she would look it over as well as have her admissions director look over it. Waiting for a response at this time. Investigation, and a review of submitted reports, revealed that the facility had submitted a report of the abuse to the Ombudsman, but not to the Office of Health Facility Licensure and Certification (OHFLAC). An interview with Administrator #48 on 06/05/24 02:42 PM revealed that the facility had not submitted a Facility Incident Report (FRI) to OHFLAC. She stated that the facility followed the reporting requirements laid out in 42 CFR 488.301, which listed actions to be taken. The copy of the guidance for reporting she provided as evidence, stated: Abuse: Resident-to-Resident - (No sexual abuse occurred, and no physician intervention was required) A report only to the Ombudsman was required, (unless the incident was caused by lack of staff or encouraged by staff). A review of the document provided to this surveyor revealed that the facility was not utilizing the current guidelines for reporting. Based on resident interview, record review and staff interview, the facility failed to report allegations of verbal abuse, neglect, and possible crime to all required stated agencies. This deficient practice had the potential to affect three (3) of 11 residents reviewed for the care area of abuse. Resident identifiers: #79, #29, and #86. Facility census: 86. Findings included: a) Resident #79 On 05/24/24, the Office of Health Facility Licensure and Certification (OHFLAC) received a complaint from an employee from a state agency reporting that marijuana, a baggy of pills, and drug paraphernalia had been removed from a resident's room by a police officer. The facility provided a log of facility reported incidences (FRIs) that had been reported to OHFLAC. The log contained no record of a FRI regarding illegal substances found in a resident's room. On 06/10/24 at 11:45 AM, the Regional Director of Operations (RDO) was asked about illegal substances being found in a resident's room. He stated neither he nor the Director of Nursing (DON) had worked at the facility at that time. The RDO stated he would ask other staff members about illegal substances being found. The following focus was found in Resident #79's Comprehensive Care Plan: Potential for safety hazard, injury r/t [related to] smoking, marijuana found in her room, medication found in her room. The initiation date was 04/23/24. The revision date was 05/31/24. Resident #79's progress note contained no information regarding the matter. On 06/10/24 at 1:45 PM, the RDO stated he had called the police department and spoke to the police chief. The RDO stated the police did not file a report or any charges. The Administrator confirmed the facility did not report the incident to OHFLAC and other required state agencies. The surveyor attempted to confirm the information with the police officer. However, no contact was able to be made through the completion of the survey process. b) Resident #29 During an interview on 06/03/24 at 1:39 PM, Resident #29 stated she had been left outside alone in the courtyard four (4) times following smoke breaks. Resident #29 stated she is unable to propel her wheelchair independently due to tremors and was unable to reenter the facility on her own. Resident #29 further stated there was no way to notify staff that she was outside and wanted to come in. The resident stated she was left out in the hot sun for two (2) hours on one day. Resident #29 also stated she had a history of falling from her wheelchair. Review of facility grievance forms showed a grievance on 05/13/24 which stated, Resident went outside with staff assistance for 1 pm smoke break. At end of smoke break as everyone returned inside [Nursing Assistant (NA) #5] said to this patient, If you can't bring yourself outside or inside, you shouldn't be able to smoke. [NA #5] then entered the building leaving this resident out in the courtyard unattended. Another resident [Resident #79] noted this patient outside alone and alerted staff. [NA #9] assisted this patient with returning to bed after 2 PM. Review of Resident #29's medical records showed a nursing note written on 5/22/2024 at 5:30 PM stated, CNA [certified nursing assistant] came to this nurse reporting resident was left outside by herself from a smoke break, patient was on the phone with [state agency] while she was present. CNA said she wanted me to be aware of. I went to patients room, patient was very tearful, she reported to this nurse that [Licensed Practical Nurse LPN #55] took her out to smoke, left her and no one returned to bring her back, says she was outside in the heat for over an hour. Patient was very upset and crying . (Note typed as written.) Vital signs were obtained and were within normal limits. Another nursing note written on 5/24/2024 at 6:28 PM, stated, This resident and another female resident from A/B side, along with male resident from C hall was offered help to come back in from smoke break. This resident and others said they were not ready at this time to come back in. All other smokers already have come back in at this time. Two of these residents is able to take self in and out of the door and were instructed that when they were ready to come in to please come get a staff member to assist this resident inside. Verbalized understanding. (Note typed as written.) Further review of Resident #29's medical records showed on 04/28/24 at 8:40 PM, the resident was found on the floor of her room in front of her wheelchair. The resident reported she had slid out of her wheelchair onto the floor. The resident received no injuries from this fall. Review of Resident #29's comprehensive care plan showed the resident required assistance of one (1) for mobility in a wheelchair. On 06/04/24 at 4:26 PM, observation of the facility courtyard was made with the Maintenance Director in attendance. No call lights were present in the courtyard. There was no push button to open the door for residents in wheelchairs to use. During an interview on 06/05/24 at 4:15 PM, the Administrator stated she was aware of two (2) instances during which Resident #29 had requested to remain outside after the smoke break had ended, 05/13/24 and 05/22/24. The Administrator confirmed the resident was not able to reenter the facility on her own. The Administrator stated she had not considered leaving the resident outside unattended to be neglectful and therefore, the incident had not been reported to the required state agencies. No additional information was provided through the completion of the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) Resident #61 On 06/03/24 at 01:58 PM, a review of Resident #61's medical record was performed including diagnoses and Resident's Pre-admission Screening (PASARR). Resident #61 was noted to have received a diagnosis of Paranoid Schizophrenia on 10/12/17, Psychotic disorder on 10/31/17 and Seizure disorder on 06/20/23, which was prior to admission to the facility. Upon review of Resident #61's (PASARR), dated as submitted on 02/08/24, it was revealed Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was not identified on the PASARR. On 06/10/24 at 11:10 AM, an interview was conducted with the facility Social Worker (SW), the SW acknowledged that Resident #61's diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was present upon admission to the facility and that Resident #61's PASARR did not identify the diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder. The SW then acknowledged that a new PASSAR including Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder had not been completed. b) Resident #58 06/04/24 3:10 PM, Review of resident #58's record revealed the resident's diagnoses include Paranoid Personality, Schizophrenia Disorder, Bipolar Disorder, Anxiety Disorder, Depression, and Schizoaffective Disorder Bipolar Type. 06/04/24 3:15 PM Review of Resident's Pre-admission Screening (PASARR) dated for 02/28/22 under section III. MI/MR ASSESSMENT, Question #30. Current Diagnosis: is checked marked as answer (a. None.) Seizure Disorder, Schizoaffective Disorder, Affective Bipolar, Schizophrenic Disorder were not marked. 06/05/24 10:10 AM Review of Resident #58's Discharge Summary from a local medical center dated for 03/14/2022 revealed, resident had discharge diagnoses of the following: -left elbow fluid collection likely osteomyelitis, history of substance abuse, chronic hepatitis C, Seizure disorder, Diabetes mellitus type 2, history of cerebrovascular accident with left-sided weakness residual, Bipolar disorder. -The medical history on this discharge summary stated that resident had a history of drug use, bipolar disorder, schizophrenia, TBI status post motor vehicle collision and bilateral lower extremity amputation. On 06/05/24 11:02 AM, an interview with Social Worker (SW) #44 acknowledged that resident #58's mental health diagnoses were not up to date on resident's Pre-admission Screening dated for 02/28/22. SW #44 reported that she was in the process of updating her PASARR's. b) Resident #53 On 06/04/24 at 10:38 AM, a review of Resident #53's medical record was performed including diagnoses and Resident's Pre-admission Screening (PASARR). Resident #53 was noted to have received a diagnosis of other seizures on 02/14/20, which was prior to admission to the facility. Upon review of Resident #54's (PASARR), dated as submitted on 03/08/21, it was revealed Resident #53's Seizure disorder was not identified on the PASARR. On 06/10/24 at 01:09 PM, an interview was conducted with the facility Social Worker (SW), the SW acknowledged that Resident #53's diagnosis of Seizure disorder was present upon admission to the facility and that Resident #53's PASARR did not identify the diagnosis of Seizure disorder. The SW then acknowledged that a new PASSAR including Resident #53's Seizure disorder had not been completed. c) Resident #61 On 06/03/24 at 01:58 PM, a review of Resident #61's medical record was performed including diagnoses and Resident's Pre-admission Screening (PASARR). Resident #61 was noted to have received a diagnosis of Paranoid Schizophrenia on 10/12/17, Psychotic disorder on 10/31/17 and Seizure disorder on 06/20/23, which was prior to admission to the facility. Upon review of Resident #61's (PASARR), dated as submitted on 02/08/24, it was revealed Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was not identified on the PASARR. On 06/10/24 at 11:10 AM, an interview was conducted with the facility Social Worker (SW), the SW acknowledged that Resident #61's diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was present upon admission to the facility and that Resident #61's PASARR did not identify the diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder. The SW then acknowledged that a new PASSAR including Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder had not been completed. Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected a pre-admission mental health diagnosis for three (3) of six (6) residents reviewed for the category of PASARR (Pre-admission Screening and Resident Review). The lack of pre-screening resulted in the residents' conditions not being evaluated through the Level II PASARR process. Resident identifier: #79, #61, and #58. Facility census: 86. Findings included: a) Resident #79 A record review, completed on 06/03/24 at 11:07 AM, found the following details: Resident #79 was admitted to the facility on [DATE] with a bipolar disorder diagnosis. There was a Pre-admission Screen (PAS) dated 04/02/24 that was completed by the referring hospital. This PAS failed to include Resident #79's bipolar diagnosis under Section III, Question #30. During an interview on 06/05/24 at 11:17 AM, the Social Worker confirmed Resident #79 had a bipolar diagnosis upon admission, the admission PAS did not capture the diagnosis, and a new PAS had not been done. The Social Worker stated the facility had overlooked the resident's bipolar diagnosis had not been captured on the initial PAS and agreed the lack of pre-screening resulted in the resident's condition not being evaluated through the Level II PASARR (Pre-admission Screening and Resident Review) process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) Resident #54 On [DATE] at 10:41 AM, a review of Resident #54's medical record was performed. Resident #54 was noted as having an order for Full Code, Full Interventions, Intravenous Fluids (IV), No Feeding Tube (NFT). A review of the Physician's Order for Scope of Treatment (POST) for Resident #53 revealed, Cardiopulmonary Resuscitation (CPR), full code with selective treatments, no artificial means of nutrition desired. A review of Resident #54's care plan was also made at this time. Resident #54's care plan was noted to have a focus that states CPR, Full Interventions, IV fluids, NFT. On [DATE] at 12:32 PM, an interview was conducted with the facility Social Worker (SW). At this time, the SW acknowledged that the POST was the correct code status per Resident #54's Medical Power of Attorney's (MPOA) wishes, that the order for Full Code, Full Interventions, Intravenous Fluids (IV), No Feeding Tube (NFT) and care plan indicating CPR, Full Interventions, IV fluids, NFT were incorrect. e) Resident #61 On [DATE] at 01:58 PM, a review of Resident #61's medical record was performed. Resident #61 was noted to have diagnoses of Paranoid Schizophrenia, Neurocognitive Disorder, Dementia, Psychotic disorder, and Seizure disorder. It was also noted during a review of the physician's orders that Resident #61 had an order for psych consult entered on [DATE], which Resident #61's behavior care plan also reflected as an intervention. On [DATE] at 09:52 AM, an interview was conducted with the facility Administrator. At this time, the facility Administrator was unable to confirm if Resident #61 had been seen by psychiatric services as ordered and care planned. On [DATE] at 02:54 PM, the facility Administrator acknowledged that Resident #61 had not seen the psychiatrist and that the care plan had not been implemented. Based on record review and staff interview, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was true for five (5) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #82, #190, #191, #54, and #61. Facility census: 86. Findings included: a) Resident #82 A record review, completed on [DATE] at 3:00 PM, revealed Resident #82 was a male admitted to the facility on [DATE]. In Resident #82's care plan the activities department expressed the following goal, I will participate in independent leisure activities of choice daily including word search, cross words, music, tv, sports, going outside through the review date, An intervention listed for this goal was, All staff to converse with her while providing care. The date this intervention was initiated was [DATE]. The care plan had a revision date of [DATE]. However, the intervention for resident's activities department goal was still, All staff to converse with her while providing care. On [DATE] at 11:21 AM, the Social Worker confirmed Resident #82 was a male and his preferred pronouns were He/Him. During an interview on [DATE] at 11:26 AM, the Activities Director acknowledged it was a mistake on her part to refer to Resident #82 as a her. b) Resident #190 A record review, completed on [DATE] at 03:05 PM, revealed Resident #190 was a male. In Resident #190's care plan the activities department expressed the following goal, I will attend activities of choice 3x per week and will pursue my favorite leisure activities daily through this review. An intervention listed for this goal was, All staff to converse with her while providing care. The date this intervention was initiated was [DATE]. The care plan had a revision date of [DATE]. However, the intervention for resident's activities department goal was still, All staff to convers with her while providing care. On [DATE] at 11:21 AM, the Social Worker confirmed Resident #190 was a male and his preferred pronouns were He/Him. During an interview on [DATE] at 11:26 AM, the Activities Director acknowledged it was a mistake on her part to refer to Resident #190 as a her. c) Resident #191 A record review, completed on [DATE] 3:42 PM, revealed Resident #191 was a male resident who was admitted to the facility on [DATE]. In Resident #191's care plan the activities department expressed the following goal, I will participate in independent leisure activities of choice daily through the review date. An intervention listed for this goal was, All staff to converse with her while providing care. The date this intervention was initiated was [DATE]. The care plan had a revision date of date [DATE]. However, the intervention for resident's activities department goal was still, all staff to converse with her while providing care. On [DATE] at 11:21 AM, the Social Worker confirmed Resident #191 was a male and his preferred pronouns were He/Him. During an interview on [DATE] at 11:26 AM, the Activities Director acknowledged it a was a mistake on her part to refer to Resident #191as a her.

Based on resident interview, record review, and staff interview, the facility failed to ensure activities of daily living (ADL) care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of activities of daily living. Resident identifier: #29. Facility census: 86. Findings included: a) Resident #29 On 06/03/24 at 1:06 PM, Resident #29 stated she had not been receiving twice weekly showers. Review of Resident #29's comprehensive care plan showed the resident had an ADL self-care performance deficit and required assistance of one (1) for bathing. Review of the facility's shower schedule showed Resident #29 was scheduled to receive showers on Tuesday and Sundays. Review of Resident #29's shower documentation for the past 30 days showed the resident received showers on 05/21/24, 05/23/24, and 05/25/24. No shower refusals were documented. On 06/04/24 at 3:56 PM, Regional Director of Clinical Operations confirmed Resident #29 had not received twice weekly showers. No further information was provided through the completion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) RSV immunization Findings included: During an interview, and record review with the Infection Preventionist (IP) #56, on 06/04/24 at 2:20 PM, it was revealed that the facility had not offered the RSV vaccination to residents during the Fall immunization period of 2023. During a subsequent interview on 06/05/24 at 09:42 AM, the Infection Preventionist (IP) #56 stated that to her knowledge, the residents had not been provided with educational information about the risks and benefits of receiving Respiratory Syncytial Virus (RSV) vaccination. She further stated that the facility had not provided residents with information on locations where they could receive immunizations, had they decided to do so. Record review on 06/05/24 at 10:03 AM revealed that Residents #17, #31, #41 and #64 had not been offered information on the RSV vaccine, the RSV vaccine, or locations where residents could receive a vaccine, if they so desired. Guidance from The Centers for Disease Control and Prevention (CDC) states that: Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization. Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV. CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making. According to the CDC the RSV vaccine was made available in early August of 2023. In general, simultaneous administration of vaccines remains a best practice. Providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences. d) Resident #191 A record review, completed on 06/10/24 at 9:58 PM, revealed the following details: Resident #191 was admitted to the facility on [DATE]. Physician order, on 04/05/24 at 12:03 PM, directed, Weekly weights every day shift every Tue (Tuesday) for 4 Weeks until finished. There was no weight listed for Tuesday, 04/09/24 There was no weight listed for Tuesday, 06/16/24 During an interview on 06/11/24 at 10:40 AM, Regional Director of Clinical Operations #116 reorted the facility was unable to produce weights for the weeks of 04/09/24 and 04/16/24. Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for 3 (three) of 11 residents reviewed for the Long-Term Survey Process. Resident identifiers: #39, #41, #191. Facility census: 86. Findings included: a) Resident #39 On 06/04/24 at 09:57 AM a review of Resident #39's medical record was performed. At this time, it was revealed that Resident #39 had a history of frequent falls. Upon further review of Resident #39's medical record, it was noted that Resident #39 had fallen 6 (six) times since January 2024. On 06/10/24 at approximately 10:30 AM, a further review of Resident #39's medical record was performed. Review of Resident #39's care plan noted an intervention that stated, medication per orders for Parkinson's. At this time, it was noted that Resident #39 had a Pharmacist Consultation Report dated 06/30/23 that stated the following: A comprehensive review of the medical record was conducted, identifying the following medications which may contribute to falls: Nuplazid at 11:00 AM, Carbidopa-Levodopa. Recommendation: Please evaluate these medications as possibly causing or contributing to this fall and consider obtaining order: - Change Nuplazid dosing time to HS (bedtime) -Orthostatic blood pressure twice daily for 2 (two) days. If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. At this time a review of Resident #39's Medication Administration Record (MAR), progress notes, vital signs and physician's orders was conducted. Resident #39 was noted to be receiving Nuplazid at 09:00 AM and that no documentation was found related to orthostatic blood pressures having been obtained. On 06/10/24 at approximately 11:15 AM, an interview was conducted with the facility ADON who stated that the Nuplazid had in fact been changed to bedtime at per the recommendation. This Surveyor then asked the ADON to provide documentation from the physician related to the risks versus benefits as to why the medication had been changed back to 09:00 AM, as per the current order and for documentation that the orthostatic blood pressures had been obtained. On 06/11/24 at 12:09 PM, an interview was conducted with the facility Medical Director and ADON. The Medical Director stated, I have no idea why it was switched back, with the ADON stating, I can't find any documentation why it was switched back. The ADON then stated that she had found documentation that orthostatic blood pressures had been obtained, however, acknowledged that the orthostatic blood pressures had not been obtained according to the physician's order. b) Resident #41 On 06/04/24 at 01:00 PM, a review of Resident #41's medical record was performed. During the review of the physician's orders, it was noted that Resident #41 had orders as follows: * Novolog Injection Solution (Insulin Aspart) Inject as per sliding scale: if 201- 250 = 4; 251- 300 = 6; 301- 350 = 8; 351- 400 = 10; 401- 450 = 12; 451 + = 15. Notify Medical Doctor (MD) if blood sugar (BS) is less than 60 or above 450, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM) II. Order date: 01/29/24 * Complete Blood Count (CBC)/Glycated hemoglobin (HgbA 1c) every 6 (six) months. Order date: 08/09/23. Upon further review of the medical record, Resident #41's Medication Administration Record (MAR) revealed multiple areas of missing documentation in reference to the above order. At this time Resident #41's diabetic care plan was reviewed which included the following intervention: *Labs as ordered and report results to MD (Medical Doctor). On 6/10/24 at12:30 PM, an interview was conducted with the DON (Director of Nursing) and ADON (Assistant Director of Nursing), this Surveyor then requested documentation related to missing blood sugar documentation and a copy of Resident #41's most recently obtained CBC and HgbA 1c. On 6/11/24 at 09:06 AM, the ADON acknowledged she was unable to locate labs, unable to confirm if the ordered labs had been obtained, or provide further information related to the missing documentation on the MAR related to Resident #41's blood sugar monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for two (2) of four (4) residents reviewed for pain during a revisit survey. Resident Identifier: #69 and #80. Facility census: 86. Findings included: a) Resident #69. Medical record review revealed Resident #69's Physician orders for pain management: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every four (4) hours as needed for pain use for pain scale 4-10. Order date 04/24/24 with a discontinue date 04/26/24. A continued review of Medication Administration Record (MAR) revealed: --04/26/24 at 9:42 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. Physician Order: Acetaminophen tablet, give 650mg every 6 hours as needed for general discomfort. Give for pain scale 1-3. Order date 04/23/24 with a discontinue date 04/26/24. No Acetaminophen tablet, administered. Physician Order: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every four (4) hours as needed for pain use for pain scale 4-10. Order date 04/26/24 with a discontinue date 05/07/24. A continued review of Medication Administration Record (MAR) revealed: --04/26/24 at 1:23 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --04/27/24 at 8:21 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. --04/27/24 at 12:53 PM pain level 2 - Hydrocodone-Acetaminophen tablet given. --04/28/24 at 7:52 AM pain level 2 - Hydrocodone-Acetaminophen tablet given. --04/28/24 at 1:26 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/03/24 at 8:01 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/03/24 at 1:00 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/04/24 at 10:37 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/04/24 at 3:38 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/05/24 at 9:22 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/05/24 at 3:34 PM pain level 1- Hydrocodone-Acetaminophen tablet given. Physician Order: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every six (6) hours as needed for pain use for pain scale 4-10. Order date 05/07/24 with a discontinue date 05/14/24. A continued review of Medication Administration Record (MAR) revealed: --05/10/24 at 8:42 AM pain level 1- Hydrocodone-Acetaminophen tablet given. --05/10/24 at 2:43 PM pain level 1- Hydrocodone-Acetaminophen tablet given. --05/11/24 at 9:15 AM pain level 1- Hydrocodone-Acetaminophen tablet given. --05/11/24 at 4:33 PM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/12/24 at 1:05 PM pain level 2- Hydrocodone-Acetaminophen tablet given. Physician Order: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every six (6) hours as needed for pain use for pain scale 4-10. Order date 05/14/24. --05/17/24 at 7:27 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/17/24 at 3:16 PM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/18/24 at 10:27 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/18/24 at 4:05 PM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/19/24 at 11:26 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/25/24 at 9:39 PM pain level 3- Hydrocodone-Acetaminophen tablet given. --05/26/24 at 5:00 AM pain level 3- Hydrocodone-Acetaminophen tablet given. --05/28/24 at 4:35 AM pain level 3- Hydrocodone-Acetaminophen tablet given. --05/31/24 at 10:03 PM pain level 3- Hydrocodone-Acetaminophen tablet given. --06/01/24 at 9:00 PM pain level 3- Hydrocodone-Acetaminophen tablet given. --06/02/24 at 9:17 PM pain level 3- Hydrocodone-Acetaminophen tablet given. Physician Order: Acetaminophen tablet, give 650mg every 6 hours as needed for general discomfort. Give for pain scale 1-3. Order date 04/26/24, No Acetaminophen tablet, administered. An interview on 06/05/24 at 5:18 PM with [NAME] Director #116, she confirmed Resident #69's Pain medication was not given per physician order. b) Resident #80 Medical record review revealed Resident #80's Physician orders for pain management: Physician Order: -Oxycodone HCl Oral Tablet 5 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for moderate pain. Order date 05/01/24 with a discontinuation date 05/15/24. A continued review of Medication Administration Record (MAR) revealed: --05/03/24 at 10:20 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --05/12/24 at 9:38 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. Physician Order: Tylenol Oral tablet 325 mg give two (2) tablets by mouth every four (4) hours as needed for pain. Order date 05/01/24 with a discontinuation date 05/15/24. --05/03/24 at 3:34 AM pain level 8 - Tylenol Oral Tablet 325 MG tablet given. Physician Order: Pain assessment every shift (sale 0-10) 0=no pain 1-3=mild 4-6=moderate 7-10=severe Every shift, Start date 05/01/24. Physician Order: -Oxycodone HCl Oral Tablet 5 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for moderate pain. Order date 05/15/24. A continued review of Medication Administration Record (MAR) revealed: --05/19/24 at 9:38 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --05/25/24 at 10:27 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --05/28/24 at 4:30 AM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --06/08/24 at 6:40 AM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. Physician Order: Tylenol Oral tablet 325 mg give two (2) tablets by mouth every four (4) hours as needed for pain. Order date 05/15/24. An interview on 06/11/24 at 12:12 PM with [NAME] Director #116, she confirmed Resident #80's Pain medication was not given per physician order. No further information was provided prior to the end of the survey on 06/11/24.

Based on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The dumpster area was polluted with uncovered garbage and medical supplies. This had the potential to affect all residents that reside in the facility. Facility census: 88. Findings included: a) Dumpster area An observation on 06/10/24 found the dumpster lid open, a trashcan full of trash without a lid and the area was polluted with garbage and medical supplies. On 06/10/24 at about 2:10 PM during an Interview the Maintenance Assistant verified the dumpster lids should be closed. He stated the garbage should not be on the ground. He also stated that he needed help getting the trash can, full of trash over the top of the dumpster. When asked how long it had been sitting there, he replied, I think just today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) Resident #54 On [DATE] at 10:41 AM, a review of Resident #54's medical record was performed. Resident #54 was noted as having an order for Full Code, Full Interventions, Intravenous Fluids (IV), No Feeding Tube (NFT). A review of the Physician's Order for Scope of Treatment (POST) for Resident #53 revealed, Cardiopulmonary Resuscitation (CPR), full code with selective treatments, no artificial means of nutrition desired. A review of Resident #54's care plan was also made at this time. Resident #54's care plan was noted to have a focus that states CPR, Full Interventions, IV fluids, NFT. On [DATE] at 12:32 PM, an interview was conducted with the facility Social Worker (SW). At this time, the SW acknowledged that the POST was the correct code status per Resident #54's Medical Power of Attorney's (MPOA) wishes, that the order for Full Code, Full Interventions, Intravenous Fluids (IV), No Feeding Tube (NFT) and care plan indicating CPR, Full Interventions, IV fluids, NFT were incorrect. b) Resident #3 On [DATE] 02:31 PM, Review of Resident #3's [NAME] Virginia Physician Orders for Scope of Treatment (POST) form on file in POST binder at the nurses station revealed the Medical Power of Attorney's (MPOA) verbal consent was taken by two (2) witnesses via telephone on [DATE], there was no record of follow up with a written signature. 2017 [NAME] Virginia Physician Orders for Scope of Treatment (POST) form regulations require mandatory signature. On [DATE] 11:00 AM, during an interview with Social Worker (SW) #44 in regards to [NAME] Virginia Physician Orders for Scope of Treatment (POST) form for Resident #3. SW confirmed the POST was not signed by MPOA and only verbal consent was obtained. She stated that she noticed this yesterday and was in the process of getting the signature. Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for residents. The facility failed to maintain an accurate medical record for two (2) of 26 sampled residents reviewed during the Long-Term Care Survey process. The facility failed to ensure Physician Orders for Scope of Treatment (POST) forms were legally valid and matched other physician orders. Resident identifiers: #79, #54, and #3. Facility census: 86. Findings included: a) Resident #79 A record review, on [DATE] at 11:07 AM, revealed a POST form in Resident #79's electronic medical record. The POST form was not dated by Resident #79. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, state, The patient or incapacitated patient's MPOA (Medical Power of Attorney) representative or health care surrogate must sign and date this section for the form to be legally valid. A review of the original POST form kept at the nurses' station revealed it also had not been dated by Resident #79. During an interview, on [DATE] at 1:20 PM, the Social Worker acknowledged Resident #79 had not dated the POST form, the form was not completed according to guidance, and it was not a legally valid document.

Based on record review and staff interview, the facility failed to develop and implement policies and procedures which addressed establishing priorities for performance improvement activities that focused on resident safety, quality of care, and high-volume and/or problem-prone areas. This had the potential to affect an unlimited number of residents. Facility census: 86. Findings included: a) Facility Reported Incidents Review of the eight (8) complaints being investigated concurrently along with the annual Long-Term Care Survey Process revealed that five (5) out of the eight (8) were facility reported incidents involving the allegation of staff verbally abusing residents. During an interview on 06/11/24 at 2:00 PM, the Regional Director of Operations #115 and the Regional Director of Corporate Operations #116 reported that to their knowledge the Quality Assessment and Assurance (QAA) Committee did not identify and/or address the pattern of verbal abuse allegations as an area for improvement. They asked the Assistant Director of Nursing (ADON) and the Infection Preventionist to join the meeting to offer their input since they had been in attendance during the QAA Committee meetings. When asked if the QAA Committee considered the five (5) facility reported incidents of verbal abuse a high-risk problem for which corrective action was required to address the underlying cause of the issue comprehensively, at the systems level, to prevent future occurrences the ADON and Infection Preventionist reported each incident was treated on a case-by-case basis. They went on to report it was never officially addressed on a systems level or officially within the QAA Committee meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain essential equipment in safe operating condition according to manufacturer's recommendations. This had the potential to affect all residents who get their nutrition from the kitchen. Facility census: 88. Finding included: a) On 06/10/24 at 11:48 AM an observation of the ice machine in the main dining room found the water drainpipe down in the sewer pipe. There was not a two-inch recommended air gap. Both the drainpipe and sewer pipe were covered with a black substance. On 06/10/24 At 11:50 AM the [NAME] Director of Dietary verified there was no gap between the drainpipe and the sewer pipe and there was at black substance present on both pipes.

Based on observation and staff interview the facility failed to incorporate an effective pest control program. This has the potential to affect all residents residing in the facility. Facility census: 88. Findings included: a) Kitchen area On 6/03/24 at 10:45 AM during a kitchen inspection there were ants in the dish washing room. On 6/03/24 at 10:50 AM during an interview the Maintenance Director verified there were ants in the kitchen area. He stated, everyone has ants, I've had them in my kitchen for about a year. He stated that the facility does not have an exterminator spray for roaches or ants. He clarified that he would spray if insects were observed by the staff. He continued to say that the exterminator only puts bait in traps outside.

Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to readily available PPE. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 86. Findings included: a) On 06/03/24 at 6:55 AM, a tour of the facility was performed. During that tour, it was noted that 3 (three) of the 4 (four) resident hallways had multiple residents on Enhanced Barrier Precautions (EBP) and that no Personal Protective Equipment (PPE) was readily available to facility staff. The observations made were as follows: On 06/03/24 at 6:55 AM, a tour of A Hall was performed. No PPE was readily available on the hall and that multiple residents were in EBP. At this time, an interview was conducted with Licensed Practical Nurse (LPN) #16 who stated, I don't know where it is, it was on the hall last week. LPN #16 also acknowledged there was no readily available PPE present. On 06/03/24 at 07:10 AM, a tour of C Hall was performed. It was observed that no PPE was readily available on the hallway and that multiple residents were in EBP. At this time, an interview was conducted with LPN #57 who stated, PPE is usually stocked on the linen carts. LPN #57 then checked the linen cart, LPN #57 confirmed that no PPE was readily available on the hallway or in the linen cart. On 06/03/24 at 7:15 AM, a tour of D Hall was performed. No PPE was readily available on the hallway and that multiple residents were in EBP. At this time, an interview was conducted with Certified Nursing Assistant (CNA) #34 who stated, It is usually on the linen cart. At that time CNA #34 checked the linen cart, confirmed that PPE was not present. CNA #34 then confirmed no PPE was readily available on the hallway or in linen carts.

. Based on medical record review and staff interview, the facility failed to ensure Advance Directive paperwork was part of Resident #11's medical record. This was a random opportunity for discovery in the complaint process. Resident identifier: #11. Facility census: 78. Findings include: a) Resident #11 An electronic medical record review, completed on 03/18/24 at 1:25 PM, identified there was a Physician Determination of Capacity, dated 09/11/23, indicating Resident #11 lacked capacity to make her own medical decisions. There was no Medical Power of Attorney (MPOA), or Health Care Surrogate (HCS) form scanned in the electronic medical record. There was a Power of Attorney (POA) form, dated 11/23/21, on file. However, the POA failed to authorize the ability to make medical decisions on resident's behalf, it was mainly meant to be a financial power of attorney. During an interview on 03/20/24 at 9:55 AM, the Social Worker confirmed Resident #11 had never completed a Medical Power of Attorney (MPOA) prior to losing capacity. The Social Worker then stated the facility did not have a Health Care Surrogate form on file or scanned into resident's medical record. The Social Worker reported the resident's physician would need to appoint a Health Care Surrogate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide a resident with a well-balanced diet that met her daily nutritional and special dietary needs. The facility failed to offer a diverticulosis diet to Resident #11 who had an identified diagnosis of diverticulosis upon admission to the facility. This was a random opportunity for discovery in the complaint process. Resident identifier: #11. Facility census: 78. Findings include: a) Resident #11 A medical record review was completed for Resident #11 on 03/18/24 at 1:25 PM. Resident #11 was admitted to the facility on [DATE] with a diverticulitis diagnosis as well as a diabetic diagnosis. Resident was placed on a carbohydrate-controlled diet. The Certified Nurse Practitioner (CNP) examined resident on 10/17/2023 and noted the following details, [AGE] year-old female being seen today related to pain/constipation. Patient has had past history of increased pain to left hip and side. X-rays were obtained and were negative for acute process. Patient does have continued complaints of increased discomfort. A nursing note, dated on 10/18/2023 at 2:35 PM, noted, Resident continues to c/o (complain of) pain on left side. An order - administration note, dated on 10/20/23 at 3:23 PM, noted, Resident complains of abd (abdominal) pain. A nursing note, dated on 10/28/23 at 3:37 PM, noted, Resident continues to complain of left sided pain. On 01/04/24 resident was seen by the CNP who noted, Patient reports abdominal discomfort and firm stools. On 01/04/24 at 3:02 PM, the Unit Manager LPN #24 documented, Resident voicing complaints to nurse that her stomach is causing her pain. This complaint has been an ongoing issue for resident . On 01/08/24 at 3:11 PM, the Unit Manager LPN #24 documented, Spoke with facility NP regarding residents ongoing complaints of abdominal pain that radiates to left side of back. New order received to obtain biannual labs as she is due for them. On 01/10/24 at 2:53 PM, the Unit Manager LPN #24 documented, Resident has been sitting up by nurses station yelling at staff b/c (because) we're not helping her with her problems. Resident c/o (complaining of) ongoing pain to abdomen. Facility NP is aware. On 01/11/24 resident was seen by the facility physician who noted, Patient complaining of increasing pain in the abdomen. In the lower abdomen. Mild to moderate. On 02/01/24 at 4:18 PM, the Director of Nursing (DON) documented, Resident came to my office to discuss her LLQ (left lower quadrant) pain. On 02/06/24 at 1:44 PM, the DON documented, Resident came to my office complaining of LLQ abdominal pain. Resident is scheduled for a Colonoscopy next month. Resident is on a waiting list per facility scheduler if there is a cancellation to have colonoscopy sooner. NP aware of c/o LLQ pain. On 02/6/24 at 2:08 PM, the Unit Manager LPN #24 documented, Facility NP followed up with resident regarding chronic c/o pain to LLQ. On 03/07/24 at 2:01 PM, the Unit Manager LPN #24 documented, Resident noted to be out of her room this afternoon pacing the halls. Resident voices c/o ongoing pain to left side of abdomen that radiates up and back her torso. It was also documented that the facility NP was aware of resident's complaints. On 03/8/24 at 11:28 AM, RN #89 documented, Resident continues to c/o left sided pain and large lump to left side that presents with some tenderness when palpated, symptoms consistent with diverticulitis flare ups, which resident does have a history of in the past. Resident happy that colonoscopy is coming up on 3/15 with (Name of Physician) and hopes to get some answers regarding pain. On 03/09/24 at 1:47 AM, LPN #25 documented, Resident does state that her abdomen is tender when palpating. Resident does have a history of diverticulitis. There was no indication that the facility Dietician had been notified of Resident #11's ongoing complaints of abdominal pain (from 10/17/23 thru 03/09/24) or that a request had been made for the Dietician to review resident's diet given the fact that she did have a diverticulitis diagnosis. During an interview on 03/20/24 at 10:10 AM, the Dietician reported that when a resident has a diverticulitis diagnosis consuming seeds and nuts can lead to inflammation and irritation which may result in abdominal pain.

Based on staff and resident interviews as well as documentation review the facility failed to ensure residents were treated with dignity and respect. Residents complained of staff having poor attitudes and not treating them with respect. Facility census: 82. Findings included: a) On 08/28/23 between the hours of 9:45 a.m. - 10:15 a.m., reviewed residential council meeting minutes from May 2023, June 2023, July 2023, and August 2023. It was noted that every month the issue was discussed regarding staff attitudes. Facility census: 82. b) Resident #46 On 08/29/23 and 08/30/23, conducted an interview with Resident # 46. Resident #46 was asked if staff treated them with dignity and respect. Resident replied, Some of them are a**holes. When I ring my call light, they will yell 'What do you want now?' On 08/31/23 at 9:34 AM during the exit conference the administrator and director of nursing had nothing to add to the issues regarding the staff's failure to ensure residents were treated with dignity and respect.

Based on record review and staff interview, the facility failed to provide evidence the required Notification of Medicare Non-Coverage (NOMNC) notice was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #192. Facility census: 89. Findings included: a) Beneficiary Notice Review On 09/13/22 at 2:04 PM, a review was completed regarding the beneficiary protection notification liability notice given for the following resident who was discharged home following her last covered day of Medicare Part A services: -Resident #192's last covered day of Part A Services was on 06/12/22. -Resident #192 was issued the NOMNC on the next day, 06/13/22. This was also the day of Resident #192's discharge from the facility. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. The Business Office Manager was interviewed on 09/13/22 at 4:13 PM to determine why Resident #192 was not issued the NOMNC at least two calendar days before her Part A services ended on 06/12/22. The Business Office Manager reported she thought maybe it was the resident's choice to leave earlier and it was considered a self-initiated discharge. In an interview on 09/14/22 at 9:45 AM, the Director of Rehabilitation Services stated Resident #192's discharge was a planned discharge from the time she entered the facility on 05/17/22. Both physical therapy and occupational therapy established resident's goal to participate in therapy services five (5) times a week for a total of four (4) weeks. Resident was noted to have made consistent progress with the skilled interventions. The Director of Rehabilitation Services stated in no way did Resident #192 initiate a discharge to home prior to her last day of Part A services. On 09/14/22 at 3:05 PM, the Administrator acknowledged the facility failed to issue the NOMNC in a timely fashion to Resident #192 prior to the last covered day of Medicare Part A skilled services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. This was true for one (1) of two (2) residents reviewed for hospitalizations/discharges during the long-term care survey process. Resident identifier: #78. Facility census: 89. Findings included: a) Resident #78 An electronic medical record review was completed on 09/13/22 at 8:49 PM. Resident #78 was discharged to the hospital on [DATE]. There was no evidence a written Notice of Transfer/Discharge was provided to Resident #78 or her legal representative. During an interview on 09/14/22 at 2:13 PM, the Manager of Medical Records stated the facility was unable to locate evidence that a Notice of Transfer/Discharge was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #80 A medical record review on 09/12/22 at 1:54 PM, revealed Resident #80 was sent to the hospital on [DATE]. During an interview on 09/13/22 at 11:20 AM the Director of Nursing (DON) stated the bed hold notice should be in chart. A medical record review on 09/13/22 at 11:21 AM, with the DON found no evidence that the facility notified the resident and/or resident representative of the facility notice for bed hold for the hospital stay on 08/06/22. During a interview on 09/13/22 at 11:24 AM, the Medical Record Manager (MRM) #10 stated I will look for it, it is probably not scanned in his chart yet. On 09/13/22 at 1:13 PM, MRM #10 stated I could not find evidence of the bed hold. Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Bed Hold Notice for a hospital transfer. This was true for two (2) of five (5) residents reviewed for hospitalizations during the long-term care survey process. Resident identifiers: #78 and #80. Facility census: 89. Findings included: a) Resident #78 An electronic medical record review was completed on 09/13/22 at 8:49 PM. Resident #78 was discharged to the hospital on [DATE]. There was no evidence a written Bed Hold Notice was provided to Resident #78 or her legal representative. During an interview on 09/14/22 at 2:13 PM, the Manager of Medical Records stated the facility was unable to locate evidence that a written Bed Hold Notice was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to develop a comprehensive person-centered care plan for each resident to meet the resident's needs that were identified in the comprehensive assessment for one (1) of 29 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: Resident # 69. Findings included: a) Resident #69 During the initial tour, on 09/12/22 at 10:30 AM, Resident #69 was observed to have both upper and lower dentures on the bedside table in a denture cup. At this time, Resident #69 stated she was needing some help with cleaning her dentures. A record review for Resident #69 showed an oral health assessment dated [DATE], that noted the resident to be edentulous (lacking teeth). Further review of the medical record, showed a care plan addressing Resident #69 as being at risk for dental care problems as evidenced by having own teeth. This care plan problem was developed on 12/22/22 and revised on 06/13/22 to note the same problem. The goal for Resident #69 noted the resident would not have any problems related to loose, broken or carious teeth with a target date of 11/27/22. An interview with the DON, on 09/13/22 at 03:23 PM, revealed Resident #69 did not have any natural teeth and confirmed the resident had both upper and lower dentures. The DON, stated further, the care plan developed for Resident #69 was not based on the assessment and was incorrect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide care to residents with pressure ulcers consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure ulcers from developing for one (1) of six (6) residents reviewed for pressure ulcers during the LTCSP. Resident identifier: Resident #81. Findings included: a) Resident #81 A record review for Resident #81, showed the resident to have a pressure ulcer located on the sacrum which was present when the resident was admitted to the facility on [DATE]. A review of the current person-centered care plan addressed the resident as being at risk for skin breakdown related to an unstageable pressure ulcer. An approach on the care plan reviewed, showed staff were required to complete a weekly skin check by a licensed nurse with weekly wound assessments of the wound status. A review of the current physician's orders showed no order for pressure ulcer treatment. Review of the weekly wound evaluations noted the following: - On 08/19/22, the wound evaluation showed the dimensions of the sacrum wound with a measured area of 0.74 cm, length of 1.82 cm and width of 0.6 cm Pressure ulcer at stage 2 on the sacrum and noted the primary dressing was a foam dressing. - On 08/29/22, the wound evaluation showed the area had increased to 2.83 cm, the length had increased to 3.67 cm and the width was documented as 0.97 cm. The wound was documented as unstageable. The treatment was documented as no dressing applied - On 09/07/22 the wound evaluation showed the area measured 6.55 cm, the length measured 6.86 cm and the width was measured as 1.44 cm. The sacral wound was identified as being an unstageable wound but was documented to be improving. At this time, the treatment was documented as cleansing with a generic wound cleanser and application of a foam dressing. On 09/13/22 at 10:50 AM, an observation of the wound was made with LPN #92. The sacrum was red but no open areas were observed. LPN #92 confirmed the only treatment for Resident #81 was for the resident to receive a skin protectant to the groin area. No treatments were verified for the pressure ulcer on the sacral area noted in the wound evaluations. An interview with RN #150, on 09/13/22 at 12:20 PM verified there was no physician's order for treatment to the sacral wound, however, Resident #81's sacral wound would be documented as healed based on the wound evaluation rounds completed this date. An interview with the DON, on 09/14/22 at 04:06 PM, verified physicians orders were required for all wound care and confirmed there had been no physician's order for the treatment of Resident #81's pressure ulcer located on the sacrum.

Based on observation, record review and staff interview the facility failed to provide appropriate assistive devices to Resident #56 in order for him to drink independently. This was a random opportunity of discovery. Resident Identifier: #56 Facility Census: 89 Findings included: a) Resident #56 On 9/13/22 at 12:25 PM, it was observed that Resident #56 did not have his nosey cup with his meal as ordered by the Physician. This was confirmed on 9/13/22 at 12:26 PM with Licensed Practical Nurse #89.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of 26 residents reviewed during the long-term care survey process had a complete and accurate medical record. Resident #75 and #52 had Physician Orders for Scope of Treatment (POST) forms completed incorrectly per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #75 and #52. Facility census: 89. Findings included: a) Resident # 75 [DATE] 12:52 PM, medical record review found: -A [NAME] Virginia POST form was completed and on file reflecting that resident was to receive Cardiopulmonary Resuscitation (CPR) and Full Treatment. Section E of the POST form entitled E. Signature: Patient or Patient Representative/Surrogate/Guardian was NOT signed but was dated for [DATE]. -The POST form was signed by the attending physician on [DATE]. During an interview on [DATE] 11:30 AM, the Director of Nursing (DON) acknowledged that a signature from Resident #75 was required on the POST form for it to be valid. b) Resident #52 On [DATE] at 1:24 PM during record review is was discovered that Resident #52's Physicians Order for Scope of Treatment (POST) did not have the required signature by the Resident or Medical Power of Attorney (MPOA). The Physician's Determination of Capacity dated [DATE] shows Resident #52 demonstrates incapacity. The Determination of Incapacity For Activation of Living Will, MPOA or Appointment of Health Care Surrogate dated [DATE] appoints his sibling as his Health Care Surrogate. This was confirmed on [DATE] at 1:25 PM, with Licensed Practical Nurse #89.

Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee consisting, at a minimum, of the Director of Nursing (DON); the Medical Director or his/her designee; and at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member, or other individual in a leadership role. Facility census: 89. Findings included: a) Quality Assessment and Assurance (QAA) Committee Meeting Attendance On 09/14/22 at 3:00 PM, a review of QAA Committee Meeting sign-in sheets from October 2021 - September 2022 was completed. There was no evidence that the Medical Director or his designee attended any QAA committee meetings in the months of October 2021, November 2021, and December 2021. During an interview on 09/14/22 at 3:39 PM, the Administrator acknowledged the Medical Director was not in attendance at any of the meetings in the October 2021 - December 2021 quarter. The Administrator stated she could not offer an explanation as to why that would have been the case [as the Administrator was not employed by the facility at that point in time]. The Administrator did agree the facility failed to maintain a QAA committee that consisted of the minimum mandatory members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure residents were served meals in a dignified manner. Residents seated at the same table did not receive meals simultaneously. This failed practice was observed as a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident Identifiers: Resident #37, #139, and #6. Census: 89 Findings included: a) Observation of the noon meal On 09/12/22 at 12:11 PM , a meal observation was made in the day area adjacent to the A/B nurses station where Resident #23, #37, #139 and #6 were observed sitting at the table. At this time, Resident #23 was eating and had finished most of the meal and had only fruit left on the tray. Residents' #37, #139 and #6 had not received any meal tray at this time. An interview, with Licensed Practical Nurse (LPN) #92, on 09/12/22 at 12:15 PM, revealed she was aware of the dignity issue of residents not being served meals at the same time when seated at the table and expressed she had brought this to staffs attention numerous times. It was also stated the tray delivery time of the B Hall and A Hall made it difficult to serve the residents within a reasonable time frame when sitting together. After the interview on 09/12/22, LPN #92 walked to the end of B Hall where the tray cart was located and served the tray to Resident #139 at 12:20 PM. Residents #37 and #6 were not served at the table until 12:45 PM when trays were delivered to A Hall. - A review of the Meal Delivery schedule, dated 03/08/21, noted lunch was served on B Hall (Butterfly Boulevard) at 12-12:15 PM and noted A Hall ([NAME]) being served at 12:40 -12:45 PM An interview, with the Director of Nursing (DON) on 09/14/22 at 03:54 PM, revealed not serving residents at the same time when seated together was a dignity issue and should not be done that way.

Based on a policy review, review of resident council minutes, resident interview and staff interview the facility failed to consider the voiced concerns of residents in resident council. The facility failed to act promptly to investigate resident grievances concerning issues of call lights and staffing attitudes. This practice has the potential to affect more than a limited number of residents living in the facility. Facility census: 89. Findings Included: A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Policy Center leadership will investigate, document and follow up on all concerns and grievances registered by any patient or patient representative a) Call lights The following Resident Council Meeting Minutes From 01/24/22 to 08/29/22 found the following documentation related to call lights concerns. --The Resident Council Minutes dated on 08/29/22, Our call lights being answered needs improvement. --The Resident Council Minutes dated on 07/25/22, Would like call lights to be answered more quickly. --The Resident Council Minutes dated on 06/27/22, Call lights being answered in a timely manner still needs improvement. --The Resident Council Minutes dated on 05/31/22, Call lights not being answered in a timely manner. --The Resident Council Minutes dated on 04/25/22, Call lights not being answered in a timely manner. --The Resident Council Minutes dated on 03/28/22, Call lights not being answered in a timely manner. --The Resident Council Minutes dated on 02/28/22, The call lights take too long to be answered. --The Resident Council Minutes dated on 01/24/22, The call lights are still not being answered in a timely manner. There was no follow up to indicate the complaints regarding call lights was addressed or resolved. b) Staffing Attitudes The following Resident Council Meeting Minutes From 01/24/22 to 05/31/22 found the following documentation related to staffing attitudes concerns. --The Resident Council Minutes dated on 05/31/22, Staff still need to better attitudes. --The Resident Council Minutes dated on 04/25/22, Staff need better attitudes. --The Resident Council Minutes dated on 03/28/22, Staff need to have better attitudes. --The Resident Council Minutes dated on 02/28/22, Some staff need better attitudes. --The Resident Council Minutes dated on 01/24/22, Some of the staff still need better attitudes. There is no follow up to indicate resident concerns regarding staff attitudes were addressed. c) Interviews --During a Resident Council meeting held on 09/13/22 at 2:38 PM by two (2) state surveyors the following question was asked; Does the facility consider the views of the resident or family groups and act promptly upon grievances and recommendations? Confidential interviews with the Resident group found the following concerns related to grievance and recommendations. --No, not really. The company runs this place. -- We tell the Registered Nurses (RN) about our grievances --Or the RN's call (the Social Service #3's name) --Tell the Nurses but nothing ever gets done. During an interview on 09/14/22 at 1:37 PM, the Recreation Director (RD) #88 stated, When there are concerns during a Resident Council meeting I fill out the resident response forms and distribute them to the appropriate departments. I don't fill out grievance forms for every concern. During an interview on 09/14/22 at 1:42 PM the Administrator stated When there is a concern from Resident Council, everyone usually talks to their staff or does in-services about the issues. I don't fill out the grievance/concerns forms, the residents complain as a group, I don't know which staff member it was or even when it takes place. I can't do anything but talk to the staff and in-service them. This surveyor stated The call light not being answered and staff attitudes has been an on going issue since before 01/22 and no improvements. During an interview on 09/14/22 at 1:55 PM The Administrator stated I have nothing to show for the resident council issues, I promise I write people up. No other information was provided.

Based on resident interview, observation, resident council meeting and staff interview, the facility failed to provide residents with a safe clean, comfortable and homelike environment. The facility failed to eliminate the institutional practices by the overhead paging of frequent announcements. The facility also failed to provide residents with furniture in good repair and resident walls in good repair . This had a potential to affect an unlimited amount of residents living in the facility. Resident Identifiers: #16 and #119. Facility Census: 89. Findings Included: a) Overhead paging During an interview on 09/12/22 at 11:37 AM Resident #16 stated That thing goes off all the time, (the overhead paging made announcement). I have hearing problems, so I can only imagine how loud it is to the other patients that live here. During a Resident Council meeting held on 09/13/22 begin at 2:38 PM, the overhead paging system interrupted the meeting at 2:55 PM, the announcement was garbled and interrupted one of the residents who was speaking. The residents in attendance of the Resident Council meeting stated concerns about the overhead paging systems and the interruption: --Sometimes it interrupts activities like in a BINGO activity. You can not hear the activity or the preachers. --It goes on all night. --Goes on forever --They page over the intercom to have a staff member go to a different part of the building. --It interrupts us eating, sleeping and when we are in activities. During an interview on 09/14/22 at 12:59 PM the Recreation Director #88 stated the overhead paging announcements disturb my activities especially when your preacher is saying a prayer. The residents usually don't say anything but the looks they give me, looks say it is interrupting. If I am conducting an activity when an announcement starts, I have to stop and repeat myself, or restart the activities. The activities it affects the most is church, trivia, bingo numbers, and exercise. Sometimes its difficult to get them to focus again when you stop if you are working with the lower functioning groups or more advanced Alzheimer residents. During the annual survey held on 08/11/22 thru 08/14/22 several observations of the overhead paging systems making several announcement,throughout the day were heard. The announcements were institutional practice, contacting interdepartmental, meal tray delivery, telephone call, alerting the nurses station of telephone calls, and maintenance supervisor pages. b) Resident #16 During an initial tour of the facility on 09/12/22 at 11:37 AM observation of Resident #16, Room C-11 found the top half of of the edge of the bed side table was hanging off. The underneath chipboard is exposed and deteriorating. During an interview on 09/14/22 at 9:31 AM, the Maintenance Supervisor #86 acknowledge the bed side table is broken, and stated I will order a new one and take this one out. He also stated that could cause her a skin tear. c) Resident #191 An observation on 09/12/22 at 2:30 PM, found there were multiple scratches, approximately 6-12 long on the wall behind resident's bed. There was also two (2) quarter-sized punctures on the wall behind resident's bed. On 9/13/22 at 11:50 AM, a second observation was made with the Director of Nursing (DON). The DON stated she would have maintenance staff repair the wall and agreed the scratches did not afford the resident a homelike environment. Resident #191 thanked the DON for agreeing to address the scratches and punctures and then reported the chair by her bed had a missing slat and was not comfortable / safe for guests to sit on while visiting. The DON agreed to have the chair switched out for a different one.

Based on observation, resident council meeting, and staff interviews the facility failed to make grievances forms accessible to residents to file a grievance anonymously. This practice has the potential to affect more than a limited number of residents living in the facility. Facility census: 89 Findings Included: a) Grievance Forms Accessibility A review of the facility policy titled Grievance/Concern with a revision date of 06/01/22 found the following. .Process . 2.1 The right to file grievances orally (meaning spoken) or in writing, the right to file grievances anonymously; . During a Resident Council meeting held on 09/13/22 at 2:38 PM by two (2) state surveyors the following question was asked; Do you know how to file a Grievance? --I think there was forms in the dining room, but have not seen them in there. --I unaware there was a form --I was not aware a paper grievance form was an option. On 09/13/22 at 3:45 PM two (2) surveyor observations throughout the facility found no grievance forms for resident accessibility. During an interview on 09/13/22 at 3:50 PM, the Administrator stated the residents ask the nursing staff for the grievance form, they are not posted for the residents to have access to. During an interview on 09/13/22 at 3:55 PM, with Licensed Practical Nurse (LPN) #89 found, When the residents ask for a grievance form I get it out of this filing cabinet and assist them in filling it out. This surveyor asked what if they wanted to take the form to their room or fill it out themselves? LPN #89 stated I would encourage them not to fill it out themselves or take it to their rooms. I need to fill out because someone needs to sign it and give it to the correct department, or fill it out correctly. This surveyor asked, How can it be anonymously, if you are filling it out?. LPN #89 stated someone needs to fill it out so they can sign it. I am new to the nursing home environment, this is the way they told me to do it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that resident centered care and services were provided in accordance with professional standards of practice. This was true for six (6) of ten (10) records reviewed for nutrition. Resident Identifiers: #30, #68, #2, #49, #78, #70. Facility Census: 89 Findings Included: a) Resident #30 On 9/14/22 at 11:30 AM record review shows the facility did not re-weigh resident #30 when he had a weight change of five (5) pounds (increase or decrease) from the last weight. According to staff interview with the Director of Nursing (DON) on 9/13/22 at 12:26 PM, staff is to re-weigh the Resident if there is a difference of a five (5) pound increase or decrease in the Residents weight. This was not performed on 3/10/22, 5/31/22, 6/20/22 and 7/06/22. This was confirmed with the DON 9/14/22 at 12:45 PM. The following weights were documented as of 9/14/22. 07/06/2022 13:25 118.6 Lbs 06/20/2022 13:56 109.4 Lbs 05/31/2022 16:15 122.4 Lbs 04/13/2022 10:17 106.0 Lbs 03/10/2022 20:33 109.0 Lbs 02/28/2022 17:54 124.0 Lbs b) Resident #68 On 09/14/22 at 3:31 PM, record review shows the facility did not re-weigh resident #68 when he had a weight change of five (5) pounds (increase or decrease) from the last weight. According to staff interview with the DON on 9/13/22 at 12:26 PM, staff are to re-weigh the Resident if there is a difference of a five (5) pound increase or decrease in the Residents weight. This was not performed on 6/13/22 and 6/21/22. This was confirmed with the DON on 9/14/22 at 3:45 PM. The following weights were documented as of 9/14/22. 6/21/2022 09:51 126.6 Lbs Standing 6/13/2022 16:26 120.8 Lbs Wheelchair 5/3/2022 11:01 139.8 Lbs Standing c) Resident #2 On 9/14/22 at 9:411 AM record review indicated Resident #2 was transferred to a local hospital on 6/29/22 and returned to the facility on 7/06/22. According the the Weights and Heights Policy revision date 6/15/22 Patients are weighed upon admission and/or re-admission . The Facility failed to obtain a re-admission weight on 7/06/22 in order to identify any significant weight change. The facility did not obtain a weight until 08/02/22. d.) Resident #49 A record review for Resident #49 revealed a physician's order, dated 05/04/22, to weigh Resident #49 every day shift every Tuesday for four (4) weeks. Further review of the resident's weight documentation, noted the facility had failed to weigh the resident in accordance with the physician's order for weights every week for four (4) weeks beginning 05/04/22. Weights documented after receiving the physician's order on 05/04/22 included a weight of 187 pounds (lbs) recorded on 05/18/22 and a weight of 185 lbs. recorded on 05/31/22. There was no evidence of weights being recorded for the week of 05/10/22 or 05/24/22. An interview with the DON, on 04/19/22 at 03:40 PM, confirmed the order for Resident #49 to have weekly weights every day shift every Tuesday for four (4) weeks, and verified the weights were not obtained in accordance with the physician's order. e) Resident #78 - Pain Medication Administered Without Pain Assessment A medical record review, completed on 09/14/22 at 8:40 AM, found the following physician order: oxycodone-Acetaminophen Tablet 5-325 MG. Give 1.5 tablet by mouth every 4 hours as needed for pain levels 6 or more do not exceed more than 3 grams of acetaminophen in 24 hours. Offer non pharmacological interventions such as position change, music, food/fluids. The start date for this order was 07/21/2022 at 7:00 PM. Review of the September 2022 Medication Administration Record (MAR) found the following dates the medication was administered without the nurse completing a pain assessment: -09/01/22 -09/02/22 -09/03/22 -09/04/22 -09/05/22 -09/06/22 -09/07/22 -09/08/22 -09/09/22 -09/10/22 -09/11/22 -09/12/22 -09/13/22 -09/14/22 During an interview on 09/14/22 at 9:10 AM, the DON acknowledged the physician order directed for pain medicine to be given if Resident #78's pain as assessed as 6-10. The DON stated the physician order was not followed since resident's pain was not assessed prior to administration of medication. f) Resident #78 A medical record review, completed on 09/14/22 8:40 AM, revealed the resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. A review of residents weights revealed the following details: -06/21/22 110.2 Lbs. Mechanical Lift -7/5/2022 134.0 Lbs. Mechanical Lift -8/15/2022 94.6 Lbs. Mechanical Lift The facility policy entitled Weights and Heights, with a revision date of 06/15/22, states patients are weighed upon admission and/or re-admission. It also states hospital weight will not serve as admission or re-admission weight. There was no evidence in the medical record to reflect resident's weight was obtained when she returned to the facility on [DATE]. The first recorded weight after resident's return was documented on 08/15/22 which reflected a 29.40% weight loss. During an interview on 09/14/22 at 9:20 AM, the DON stated the re-admission weight was not done. g) Resident #70 A medical record review, completed on 09/14/22 at 6:00 AM, found the following physician order: Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet by mouth every 4 hours as needed for pain. Scale of 5-10. Start date for this order was 08/05/22. Review of the September 2022 Medication Administration Record (MAR) found the following dates the medication was administered outside the scope of the physician order : -On 09/04/22 at 12:55 PM, Resident #70 was assessed by the nurse to have a pain level of 4. Resident was administered the medication. During an interview on 09/14/22 09:25 AM, the DON stated the physician's order was not correctly followed since the medication was administered when resident's pain level was assessed as a four (4).

Based on anonymous resident interviews, anonymous staff interviews, resident council minutes, a resident council meeting held during the long-term care survey, and interviews with Administration, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. Facility census: 89. Findings Included: a) Anonymous Resident Interviews During an anonymous resident interview on 09/12/22 at 11:06 AM, Resident #301 stated the facility doesn't have enough staff. It would be the resident's preference to get up and be dressed earlier, but there simply isn't enough staff available to honor that preference. During an anonymous resident interview on 09/12/22 at 11:37 AM, Resident #302 stated I am going blind, and need more help, but there is not enough staff. I put my call light on and when they answer it, they turn it off and never come back. The say they don't have time. During an anonymous resident interview on 09/12/22 at 1:31 PM, Resident #303 stated the call light is not answered in a timely fashion. The call button is useless. During an anonymous resident interview on 9/13/22 at 2:16 PM, Resident #304 stated the company [corporate] is cutting the budgets at the facility which seems to have affected staffing. Resident reported, This week we have lots of staff present since state surveyors entered the building on Monday. Lots of times we only have one (1) aide on one side and two (2) aides on the other side. Sometimes, we just have one (1) aide per side. Resident went on to state that complaints about staffing do not get addressed or resolved. Resident stated he/she had personally complained about staffing in Resident Council meetings, to the Director of Social Services, and the Administrator. Resident reported having no success in any staff member helping resolve the concern and stated, I might as well beat my head against the wall. It would have the same effect. b) Staff Interviews Anonymous Nurse Aide (NA) Interview #1 was conducted on 09/13/22 at 12:25 PM. The NA stated, There is not enough staff. Staff are required to work overtime and stated a lot of the time, there is only one nurse aide on a wing. The assigned LPN [Licensed Practical Nurse] is not always able to help you. The NA went on to state, This past weekend, I worked alone. On Monday [9/12/22] there was only nurse aide working on A Wing, but when surveyors walked in, they pulled the laundry aide [who is also a Nurse Aide] to work the floor. Anonymous Nurse Aide (NA) Interview #2 was conducted on 09/13/22 at 12:58 PM. The NA stated working alone on the unit happens a lot and it is difficult to care for residents who require two-person assist. Anonymous Laundry Worker Interview #3 was conducted on 09/14/22 at 12:45 PM. The laundry worker reported there are times that she is left in the laundry alone because her coworker [who is also a Nurse Aide] is pulled to work the floor to fill in staffing gaps. c) Resident Council Minutes A review of the Resident Council minutes from January 2022 through August 2022 found resident complaints about the facility being short on staffing and the length of time it took to answer call lights: -The Resident Council Minutes dated on 01/24/22, The call lights are still not being answered in a timely manner. -The Resident Council Minutes dated on 02/28/22, The call lights take too long to be answered. -The Resident Council Minutes dated on 03/28/22, Call lights not being answered in a timely manner. -The Resident Council Minutes dated on 04/25/22, Call lights not being answered in a timely manner. -The Resident Council Minutes dated on 05/31/22, Call lights not being answered in a timely manner. -The Resident Council Minutes dated on 06/27/22, Call lights being answered in a timely manner still needs improvement. -The Resident Council Minutes dated on 07/25/22, Would like call lights to be answered more quickly. -The Resident Council Minutes dated on 08/29/22, Our call lights being answered needs improvement. The facility failed to meaningfully address the resident council concerns about extended wait times for call lights to be answered. The facility was unable to provide evidence of a thorough investigation including statements from the residents making the allegations to determine the length of time residents were waiting for staff to answer call lights and any adverse consequences of waiting extended periods of time, statements from any other residents regarding the care they had received during the same time frames reported, statements from the staff working at the time of the incidents, or statements from the staff who had knowledge or involvement in the incidents. The Administrator also failed to provide evidence the facility investigated the staffing level in the facility at the time of the incident to ensure adequate staff was deployed to meet the resident's needs. d) Resident Council Meeting. During a resident council meeting, on 09/13/22 at 2:38 PM, residents expressed the following staffing concerns: - They have not acknowledged our staffing concerns and/or offered feedback. - The company runs this place and went on to state Resident feedback is not considered. - They need more help. - It's not always their fault when it takes a long time to answer our call lights. They are short-handed. - We want to be treated as human beings. We don't like it when they rush to get out of the room. - They are under a lot of tension. When they get out of sorts (not the older ones as much) the younger ones have no problems degrading us. - We're not contributing money in the system right now. But I have earned my way to have someone take care of me. I've paid my taxes and paid my dues. I should have the care I need. f) Review of the Facility Staffing Review of facility staffing was completed on 09/14/22 at 11:00 AM. The review confirmed that Laundry Aide #45 was pulled to work the floor on Monday, September 12, 2022, for the day and evening shifts. h) Director of Nursing (DON) Interview During an interview on 09/14/22 at 3:02 PM, the DON acknowledged the above-mentioned resident and staff concerns and stated that although the facility did not have any evidence the repetitive resident council complaints about staffing had been investigated, We never go below the state minimum hours per resident day. If that were to happen employees in Nurse Management positions would jump in and help.

Based on observation and staff interview the facility failed to employ a clinically qualified nutrition professional on a full time basis to manage the daily function of the kitchen. This had the potential to affect all the residents that receive nutrition from the kitchen. Facility Census: 89. Findings Included: a) a) Qualified Nutrition Professional An observation of the kitchen office on 09/13/22 at 9:04 AM, revealed no certified licensed professional certificates. During an interview on 09/13/22 at 9:04 AM, Dietary Manager #34, stated I am enrolled in the Dietary Mangers class, I will be testing in February. During an interview on 09/13/22 at 9:04 AM interview District Manager of Dietary #112 stated, we do not have a full time certified dietary manager, I am here a few days a month and the dietician is here two (2) to three (3) days a week.

Based on observation and staff interview the facility failed to store food in a safe and sanitary manner in accordance with professional standards for food service safety. The facility failed to keep kitchen equipment clean and rust free. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Facility Census: 89. Findings Included: a) Ice Machine A review of the facility policy titled 4.0 Cleaning Standards with a revision date of 06/15/18 found the following. .Cleaning Procedure Ice Machine ( Bin type) When: Monthly On 09/12/22 at 9:50 AM a tour of the kitchen with Dietician #111, the ice machine in the main dining room revealed to have black substance in the inside of the machine. The Dietician #111 acknowledged the black substance. During an interview on 09/12/22 at 9:55 AM, [NAME] #101 stated the maintenance cleans the ice machine not the dietary department. I don't know the last time it was cleaned. During an interview on 09/12/22 at 10:05 AM the Maintenance Supervisor(MS) #86 stated we clean the ice machine every three month, its due this month. MS acknowledged the black substances and tried to scrap it off with his fingernail. The Dietary Manager (DM) #34, was also present during the interview and acknowledged the black substance in the ice machine. The MS #86 provided a record of sanitation of the ice machine completed on 06/17/22. b) Clean and Rust free equipment During the initial tour of the kitchen on 09/12/22 at 10:07 AM with the Dietary Manager #34 found the following items: --Cook's preptable bottom shelving was rusted. --Aide's Prep table bottom shelving was rusted. --Two shelving units used for container/dish storage were rusted. The DM #34 acknowledged the rust issues on al kitchen equipment. c) Hand Hygiene Sink water A review of the facility policy titled Hand Hygiene with a revision date of 11/15/21 found the following. .Process . 2. Hand Hygiene techniques: 2.1 To wash hand with soap and water: Wet hands with warm (not hot) water, apply soap to hands, and rub hands vigorously outside the stream of water for 20 seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel During an tour of the kitchen on 09/12/22 at 9:50 AM, Dietician #111, This surveyor began washing her hands, the water was not getting warm, then it would turn cold and back a little warm. The Dietician #111 started to wash her hands, and stated the water is not hot enough, its barely warm, now its cold. I will call the maintenance supervisor. On 09/12/22 at 10:02 AM the MS #86 placed his thermometer under the water which had been running for 12 minutes, it read 89.9 degrees Fahrenheit and stated, it should be 110-115 degrees that is not warm enough. The MS placed hands under running water and acknowledged the water turning from warm to cold. He stated I will have to fix it, I think I know what's wrong with it. We will close the sink till I get it fix. The hand hygiene sink did not have accurate warm water to maintain proper hand hygiene procedure.

Based on review of facility documents and staff interview, the facility failed to ensure the designated individual acting as the Infection Preventionist completed a specialized training in infection prevention and control. This failed practice had the potential to affect all residents residing in the facility. Census: 89 Findings included: a) Infection Preventionist A review of facility infection control documents, on 09/14/22, showed no evidence of any individual designated to serve as the infection preventionist who had completed a specialized training in infection prevention and control. An interview with the (Director of Nursing) DON, on 09/14/22 at 12:40 PM , revealed the facility had hired a new employee for that role, but the DON had been filling in as the Infection Preventionist. The DON stated neither staff member had a certificate of completion of a required Infection Preventionist course. The DON confirmed, at the present time, no staff members had obtained additional training and were certified as an Infection Preventionist.